Reading between the lines of breast cancer treatment studies

Between the Susan G. Komen-Planned Parenthood debate and the study on treatments released by the Journal of the American Medical Association recently, breast cancer has certainly gotten a lot of play in the media as of late.

Every major news outlet in America covered the breast cancer study released by JAMA which said that nearly half of the women who had second surgeries for breast cancer may not have needed the operation. Taken on face value, this statistic is misleading and could drive women with breast cancer away from the health systems that can help them the most.

Integrated health systems versus traditional systems

Three of the four organizations in the study are integrated health systems, where the role of both payer and provider are combined. They are Kaiser Permanent Colorado, the Marshfield Clinic in Wisconsin and Group Health in Washington. The study participants were part of managed care, where physicians are on salary and tend to coordinate care amongst providers, are more likely to follow evidence-based guidelines set by the medical leadership, and have no incentive to bill for extra procedures as they might in fee for service medicine.

Contrary to the reports, Innosight Institute’s studies have shown that the traditional system in which the majority of Americans participate tend to have higher rates of excess or unnecessary procedures than the integrated health systems identified. Just because the systems in the study didn’t have great results doesn’t make them worse than your health system, it just makes them the first brave souls to share their data. In fact, studies have shown that care in integrated health systems is actually better.

Innosight Institute’s research, in addition to independent metrics collected by Dartmouth Health Atlas, the National Committee for Quality Assurance and federal reporting agencies, shows that these systems actually do better than most other healthcare organizations in providing care that is both lower cost and higher quality.

More importantly, they tend to provide less excessive or unnecessary care than most other organizations. And sure enough, when you look at the fine print of the JAMA study, it says the 22.9 percent rate of second surgeries “is lower than previous studies demonstrating re-excision rates of 36 percent to 50 percent…the re-excision rates [in the JAMA study] are considerably lower than would be predicted based on 3 recent surveys of practice patterns for close margins.”

Put simply, these surgeons were more cautious about second surgeries than most other institutions. So in all likelihood, most places women receive care actually have a far higher rate of unnecessary second surgeries, proving the point that one should not avoid the four health systems on this list, but on the contrary, prioritize around getting care there.

Electronic medical records in integrated health systems

Another facet that went unreported is why these particular study sites were chosen rather than a more representative array of healthcare systems where the payer and provider are separated. Such studies can only be conducted at a large scale if there is access to accurate and thorough medical records. Researchers turn to large integrated health organizations time and again for studies on cancer screenings, drug side effects, caesarean rates, and all kinds of other urgent public health concerns because only integrated health organizations have been keeping robust electronic medical records for a decade or more.

As noted in the fine print of this study: “Data were obtained from electronic medical records and chart abstraction … data from the University of Vermont were entirely abstracted from medical records.” So, the one health system that was not integrated required far more onerous chart analysis to produce usable data. Until the rest of our healthcare system makes both the financial investments and also organizational commitments to robust electronic medical records, researchers are hamstrung.

Extrapolating between apples and oranges makes no sense. Care at Kaiser Permanente is delivered, coordinated, and reimbursed entirely unlike care available in most cities in the country. Researchers are ultimately unable to tell us much about the kind of care most of us get at most healthcare organizations, and that’s the truly alarming headline.

Vineeta Vijayaraghavan is a senior research fellow at Innosight Institute, a think tank focused on disruptive innovation. Clayton Christensen is the Kim B. Clark Professor of Business Administration at Harvard Business School and co-founder of Innosight Institute.