Shots - Health Blog
Wed April 4, 2012
Doctors Urge Their Colleagues To Quit Doing Worthless Tests
Nine national medical groups are launching a campaign called Choosing Wisely to get U.S. doctors to back off on 45 diagnostic tests, procedures and treatments that often may do patients no good.
Many involve imaging tests such as CT scans, MRIs and X-rays. Stop doing them, the groups say, for most cases of back pain, or on patients who come into the emergency room with a headache or after a fainting spell, or just because somebody's about to undergo surgery.
A child with low belly pain and suspected appendicitis? Don't rush her to the CT scanner. Do an ultrasound first. That will give the answer 94 percent of the time, is cheaper and doesn't expose the child to radiation.
Don't put heartburn patients on high doses of acid-suppressing drugs when lower doses and shorter courses will do, they say. You might just be making their symptoms worse when they try to stop the medicine.
An apparently healthy middle-aged guy with few cardiac risk factors comes in for a yearly exam and wants to know how his ticker is. Don't give him a full cardiac workup, with a treadmill test and fancy imaging. This kind of patient accounts for almost half of unnecessary cardiac screening.
Postpone repeat colonoscopies for 10 years if the first one is negative, or if it found and removed one or two early-stage colon polyps, the guidelines state. And stop prescribing antibiotics for mild-to-moderate sinus infections.
And here's one that raises some tricky questions: Most patients who are debilitated with advanced cancer shouldn't get more chemotherapy.
"When somebody is literally bed-bound and unable to walk or take care of himself, it's almost futile to use cancer-directed treatment and will probably have negative consequences," says Dr. Lowell Schnipper, a Boston cancer specialist who helped develop the new guidelines.
Schnipper tells Shots many cancer patients are getting chemotherapy in the last weeks of their lives. He says that does no good, makes patients miserable and may shorten their life.
The Choosing Wisely project was launched last year by the foundation of the American Board of Internal Medicine. It recruited nine medical specialty societies representing more than 376,000 physicians to come up with five common tests or procedures "whose necessity ... should be questioned and discussed."
The groups represent family physicians, cardiologists, radiologists, gastroenterologists, oncologists, kidney specialists and specialists in allergy, asthma and immunology and nuclear cardiology.
Eight more specialty groups will join the campaign this fall, representing hospice doctors, head and neck specialists, arthritis doctors, geriatricians, pathologists, hospital practitioners, nuclear medicine specialist and those who perform a heart test called echocardiography.
Consumer groups are involved, too. Led by Consumer Reports, they include the AARP, National Business Coalition on Health, the Wikipedia community and eight others.
The effort represents a growing sense that there's a lot of waste in U.S. health care, and that many tests and treatments are not only unnecessary but harmful.
Harvard economist David Cutler estimates that a third of what this country spends on health care could safely be dispensed with.
"That's certainly the number we use," Dr. Steven Weinberger, CEO of the American College of Physicians, tells Shots. "Most of us feel something like $750 billion or so could be eliminated from the system out of the $2.5 trillion or so that we spend on health care."
Weinberger says unneeded diagnostic tests probably account for $250 billion.
"I talk about this a fair amount around the country, and invariably physicians come up to me and recount their own anecdotes about overuse and misuse of care," he says.
Proponents of the campaign are aware they're wading into dangerous waters. "There will be some ... that may demonize this campaign and infer the R-word — rationing," Daniel Wolfson of the ABIM Foundation wrote in December when the campaign was launched.
But rationing is the denial of care that patients need, Wolfson points out. The Choosing Wisely campaign aims to reduce care that has no value.
ROBERT SIEGEL, HOST:
Groups representing hundreds of thousands of doctors are launching a new campaign that is bound to stir controversy. Their goal is to stop tests and treatments that don't do patients any good. The effort is also the support of some leading consumer groups.
As NPR's Richard Knox reports, the campaign is the first step toward limiting procedures that account for a giant chunk of the nation's medical bill.
RICHARD KNOX, BYLINE: They're calling it choosing wisely. Doctors leading the campaign say about a third of what the nation spends on health care could be done away with without harming anybody, but at this point, the campaign has more modest goals. They could add up to maybe 10 percent of current spending, or around $250 billion a year. To do that, doctors would have to cut way back on 45 common tests and procedures.
The effort was organized by the American Board of Internal Medicine Foundation. It asked specialty groups to name the top five things that patients would be better off without.
JOHN SANTA: This is a good place to start, the lowest hanging fruit.
KNOX: That's Dr. John Santa of Consumer Reports, which is working with the physician groups. The list is a broad swath of everyday medical tests and procedures. For instance, most patients with back pain shouldn't get CT scans or MRIs. Neither should people with ordinary headaches or feinting spells or a child with suspected appendicitis. For that, a cheaper ultrasound will nearly always do with no radiation.
The doctors say too many patients are getting fancy cardiac workups and repeat colonoscopies, antibiotics for sinus infections, and so on.
Santa says this first set of recommendations generally doesn't get at the most controversial kinds of tests.
SANTA: You know, there are some really tough ones. Screening for breast cancer and prostate cancer. Notice these aren't chosen because those are tougher.
KNOX: But that doesn't mean the doctor groups avoid at all the difficult ones. Probably the most touchy is one put forward by the American Society of Clinical Oncologists, cancer doctors. They say most patients with advanced cancer should not get chemotherapy treatments if they're not likely to benefit.
Dr. Lowell Schnipper is a Boston oncologist who helped draw up the list.
LOWELL SCHNIPPER: We are doing the vast majority of people no favor by treating them into their coffins and I think most oncologists understand that.
KNOX: Some studies indicate that 35 percent of cancer patients or more receive chemotherapy in their last two weeks of life. Schnipper says, except in rare cases, they'd be better off getting hospice care and might even live longer.
SCHNIPPER: It's highly unlikely that anything we do to people so far advanced in their illness is likely to bring them much respite.
KNOX: But that recommendation - and maybe some others - may become a lightning rod for a charge that is often raised by these discussions that this is rationing.
SANTA: We're certainly expecting it and I think we're very emphatic that we're not talking about rationing here.
KNOX: Again, that's Dr. John Santa of Consumer Reports.
SANTA: It's not denying services to people who need it. Quite the contrary, it's identifying who needs it and who doesn't, getting it right.
KNOX: There will be plenty of opportunity to debate these issues. Proponents plan to keep at it for several years and more physician and consumer groups will join the campaign this fall.
Richard Knox, NPR News. Transcript provided by NPR, Copyright National Public Radio.