Surgeries often unnecessary, study suggests
Elective operations: Doctors prescribe procedures without first assessing need

Brad Evenson
National Post

Tuesday, September 03, 2002

Surgeons across Canada often perform elective surgery on patients with little regard to whether they need it or not, a new study has found.

The three-year study, which looked at procedures such as cataract surgery, hysterectomy and total hip replacement, found patients are often unsatisfied with their results, but surgeons often do not seem to care.

"Some surgeons may have difficulty accepting the evidence that patients' self-reported [quality of life] is a more valid outcome measure than their own impressions of outcomes," says the study, published today in the Canadian Medical Association Journal.

Roughly 50% of all hospital admissions for surgery are for elective procedures, which are defined as non-life- or limb-threatening. But with skyrocketing health care costs, researchers have begun seeking ways to determine who should have these expensive operations.

For example, the number of hysterectomies (the surgical removal of the uterus) performed varies sharply across the country. So does the rate of birth by Caesarean section.

"All you can say is there is no good medical explanation for the very large differences in surgery for these elective things," said lead investigator Charles Wright of the Centre for Clinical Epidemiology and Evaluation at Vancouver Hospital and Health Sciences Centre.

The researchers looked at six common operations and found patients often appeared to have little need for surgery.

For example, 32% of patients booked for cataract surgery scored higher than 90 points on a 100-point scale, suggesting their vision was reasonably good.

When the patients were asked to fill out a health-related, quality-of-life questionnaire, 27% of the cataract patients said they had little or no improvement in their vision.

"Look at the cataract results, which were less than stellar, and you might suggest that some of the ophthalmologists should be a little more selective in the patients that they choose to operate on," Dr. Wright said.

"I'm not going to blame the surgeons 100% because we have a society where people expect everything to be dealt with and I'm sure a lot of these people with cataracts ... had very minimal disability. Maybe they're beginning to get just a little bit of haze at night on their vision and they go running to their doctor."

By contrast, 94% of patients who had a total hip replacement said their quality of life improved.

"If you've got severe pain in your hip and you can't go shopping and you can't wipe your own [bottom], then of course you're going to accept the risks and the [quality of life] results, consequently, are very good," Dr. Wright said.

"Whereas if you have very, very minor interference with your vision, you're going to be very upset if you get a surgical complication that makes you half-blind. That doesn't happen very often, but it can happen."

When surgeons in the study were shown the patient questionnaires, they were not enthusiastic. Almost half said they were not interested in such information.

"Patients always believe the surgery will be miraculous and solve all their problems," said an Ottawa surgeon who asked not to be identified.

"So even if you perform a 100% perfect procedure, with no infection, minimal scarring and no complications, they're going to complain. How is that relevant?"

In fairness, Dr. Wright says, tools such as quality-of-life questionnaires are fairly new. However, he said similar tools, such as questionnaires about how badly they need surgery, will someday be a fact of life in Canadian hospitals.

"I think that's entirely reasonable" in an environment where health costs must be controlled he said. "And that's going to happen as we get more rigourous in this sort of thing."