Putting the Brakes on Treatment

Doctors list tests and procedures to avoid. Consumers will get the message.

  • Should low-risk patients absent any symptoms get an EKG at their annual checkup?
  • Do women under 65 or men under 70 really need to be screened for osteoporosis with dual energy X-ray absorptiometry (DEXA)?
  • Should women under age 21 get routine Pap smears?
  • Do average-risk patients need any kind of colorectal cancer screening more frequently than 10 years after a high-quality, negative colonoscopy?

Given continuing concerns about healthcare cost and quality, questions such as these are likely to crop up with greater frequency in the months and years ahead. To be sure, Journal of Healthcare Contracting readers won’t be charged with coming up with the answers. But they will have a front row seat to some of the greatest debates around. And the outcome of those debates will influence what and how many supplies and equipment are brought into the IDN.

Campaign launched
In April, nine leading physician specialty societies launched their “Choosing Wisely” campaign by publishing a list of 45 tests or procedures (five from each specialty society) that they say are commonly used but not always necessary. The lists of “Five Things Physicians and Patients Should Question” are said to provide specific, evidence-based recommendations that physicians and their patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.

The “Choosing Wisely” concept was originally piloted by the National Physicians Alliance, which, through an American Board of Internal Medicine Foundation “Putting the Charter into Practice” grant, created a set of steps physicians in internal medicine, family medicine and pediatrics could take in their practices to promote the more effective use of healthcare resources. These steps were first published in the Archives of Internal Medicine.

Since then, the movement has grown. The nine organizations releasing lists represent nearly 375,000 physicians. They are:

  • American Academy of Allergy, Asthma & Immunology.
  • American Academy of Family Physicians.
  • American College of Cardiology.
  • American College of Physicians.
  • American College of Radiology.
  • American Gastroenterological Association.
  • American Society of Clinical Oncology.
  • American Society of Nephrology.
  • American Society of Nuclear Cardiology.

And the heat will only mount. In April, ABIM announced that eight additional specialty societies were joining the “Choosing Wisely” campaign. They were expected to release their lists this fall.

These recommendations will have legs
“Choosing Wisely” follows by two years the launch by the American College of Physicians of its “High Value, Cost-Conscious Care” initiative. That initiative was created to assess benefits, harms and costs of diagnostic tests and treatments for various diseases. At the time of its announcement in 2010, ACP quoted a Congressional Budget Office estimate that 5 percent of the nation’s Gross Domestic Product – or $700 billion a year – is spent on tests and procedures that do not actually improve health outcomes. “ACP contends…that savings can be achieved by reducing inappropriate utilization of services and by encouraging clinically effective care based on comparative effectiveness research,” the College said at the time.

Unlike many evidence-based recommendations, which receive a day or two of screaming national coverage, never to be heard of again, the recommendations in “Choosing Wisely” are expected to have legs. That’s because Consumer Reports, with more than 8 million subscribers, has agreed to partner with the specialty societies and ABIM to address the value and quality of various diagnostic tests and medical procedures, just as it does cars, toothpaste and vacuum cleaners.
In fact, the magazine announced that 11 consumer-oriented organizations would join “Choosing Wisely” to help disseminate information to the public. They include the AARP, Leapfrog Group, the National Business Group on Health, and the Service Employees International Union.

Overuse of healthcare resources
“Many experts agree that the current way health care is delivered in the U.S. contains too much waste – with some stating that as much as 30 percent of care delivered is duplicative or unnecessary and may not improve people’s health,” said the ABIM in a statement announcing the “Choosing Wisely” campaign. “In fact, such unnecessary care may harm or hinder patients’ health.
“The Choosing Wisely campaign is designed to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources in the United States. By creating and releasing [the] lists, the groups aim to stimulate discussion about the need – or lack thereof – for many frequently ordered tests or treatments, many of which are requested by patients. The groups also hope to support physician and patient relationships by encouraging specific conversations about appropriate individualized testing and treatment plans.”

Following are just a few of the nine specialty societies’ lists of overused tests and procedures. (For the full text of all lists and their rationale, go to www.choosingwisely.org.)

  • Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
  • Don’t diagnose or manage asthma without spirometry.
  • Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
  • Don’t order annual electrocardiograms or any other cardiac screening for low-risk patients without symptoms.
  • Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
  • Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms, unless high-risk markers are present.
  • Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
  • Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
  • Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
  • In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
  • Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
  • Don’t do imaging for uncomplicated headache.
  • Don’t image for suspected pulmonary embolism without moderate or high
    pre-test probability.
  • Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
  • Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.
  • Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
  • Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.
  • For a patient with functional abdominal pain syndrome, CT scans should not be repeated unless there is a major change in clinical findings or symptoms.
  • Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status, no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment.
  • Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis, or early breast cancer at low risk for metastasis.
  • Don’t perform surveillance testing (biomarkers) or imaging (PET, CT or radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
  • Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
  • Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.
  • Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.