Physician groups list 45 overused tests, procedures

Apr. 05, 2012
Physician groups list 45 overused tests, procedures
Deborah L. Shelton and Julie Deardorff | McClatchy-Tribune News Service

CHICAGO — Should you get a cardiac stress test as part of your annual checkup? A chest X-ray before outpatient surgery? A CT scan or antibiotics for chronic sinusitis?

In most cases, no.

But patients get these commonly used tests and procedures - and many more - all the time, even though medical experts say they often are unnecessary, can be harmful and contribute to the nation's skyrocketing health care costs.

On Wednesday, nine physician specialty societies collectively representing about 375,000 physicians nationwide are each unveiling a top five list of tests or procedures commonly used without good cause.

The American College of Cardiology, for example, says stress tests are unnecessary for otherwise healthy adults without cardiac symptoms because they rarely result in any meaningful change in patient care.

The American College of Radiology recommends against chest X-rays before outpatient surgery for patients who have normal physical exams and no previous problems because the images do not usually change patient care and have not been shown to improve patient outcomes.

And the American Academy of Allergy, Asthma & Immunology says that because most cases of acute rhinosinusitis can be diagnosed clinically and resolved without treatment in two weeks, there is no need for antibiotics or a sinus CT scan or other imaging.

The lists, which include information about when a particular test or treatment may be appropriate based on clinical evidence and guidelines, are part of the Choosing Wisely campaign, a multiyear effort aimed at reducing the use of unnecessary medicine and promoting greater dialogue between patients and physicians.

The Congressional Budget Office estimates that up to 30 percent of health care expenditures in the U.S. go toward tests, procedures, doctor visits, hospital stays and other services that many medical experts say do not improve patients' health.

"Unfortunately, in some of the political rhetoric about health care costs and all of the accusations about rationing, consumers get understandably worried," said Dr. Christine Cassel, president of the American Board of Internal Medicine and ABIM Foundation, which organized the Choosing Wisely campaign.

Patients "think more is better, and 'Maybe I'm not getting something I need,' when, in fact, more is not necessarily better," she said. "There are a number of things that not only aren't necessary and are potentially costly, but also have a risk of harm to the patient."

The lists cover a wide range of tests, procedures and treatments, some of which are routinely used for thousands, even millions, of patients. Others are only for specific kinds of patients such as those with certain cancers or undergoing kidney dialysis.

For example, the American Society of Nephrology said dialysis patients with limited life expectancies - six months or less - and no signs or symptoms of cancer shouldn't get routine cancer screening, including mammograms, colonoscopies, Pap smears and PSA tests.

The American Society of Clinical Oncology, which is meeting in Chicago this week, recommended against using advanced imaging technologies such as PET, CT and radionuclide scans to determine cancer spread in patients with early-stage breast cancer and prostate cancer that is at low risk of metastasizing.

In both cases, the tests can lead to unneeded invasive procedures, overtreatment, unnecessary radiation exposure and misdiagnosis.

Some outside experts applauded the effort to reduce unnecessary care.

"The greatest advance in medicine in the past 50 years is not the latest wave of good ideas. It's the ability and mandate to ask whether any idea advantages any patient, and if so, how much?" said Dr. Nortin Hadler, author of "Worried Sick: A Prescription for Health in an Overtreated America."

"These lists scratch the surface of good ideas that have proved disappointing at best," Hadler said. "Every patient has the right to ask a physician 'How certain are you that any particular test or intervention will advantage me?' and expect an informative answer."

Others said the campaign has shortcomings.

Dr. Adam Cifu, an associate professor of medicine at the University of Chicago and co-author of a clinical reasoning textbook called "Symptom to Diagnosis: An Evidence-based Guide," said the list is a good start but two things seem problematic.

One is that the recommendations come from sub-specialty groups, which means they're a little biased in terms of the patients they see, Cifu said.

For example, the American Academy of Allergy, Asthma & Immunology recommends against diagnosing asthma without spirometry, a test using a device that measures air flow. But general internists, pediatricians and family practitioners see simpler asthma cases and may not need the tool, which can be costly, he said.

Cifu also said groups often choose the least debatable problems, which might not have the greatest impact.

Dr. Steve Devries, a preventive cardiologist at Northwestern Memorial Hospital, said the procedures on the list are still common practice.

"There's a natural inclination to screen for heart disease in people before they have symptoms. The idea is if heart problems are identified early, a heart attack can be prevented," he said.

But the stress test as a 50th birthday present hasn't panned out, said Devries. "An abnormal stress test often leads to an angiogram which, if confirming a narrowed artery, often leads to a stent procedure," he said. "Unfortunately, placing stents in people who do not have symptoms has not been shown to prevent heart attacks or save lives."

What does prevent heart attacks, Devries added, is eating a Mediterranean diet, as well as exercise and, for selected high-risk individuals, aspirin and cholesterol medication.

Cassel said both physicians and patients need to talk about frequently ordered tests or treatments, many of which are requested by patients. She said she hopes the lists also encourage more discussion about appropriate individualized testing and treatment plans.

"It's (a responsibility of) both patients and doctors," she said. "Physicians sometimes are reluctant to say 'You don't need this.' Or they are afraid of malpractice. If patients have the same information as the doctor, they can ask if they really need it. They start on a level playing field, which leads to shared decision-making, which is a model of medical care that leads to the best outcomes."

Dr. Ronald Falk, president of the American Society of Nephrology, said his organization first came up with a list of about 100 overused tests and treatments before it whittled it down to five.

Many of the group's concerns had to do with the use of medications, such as non-steroidal anti-inflammatory drugs, in patients with hypertension, heart failure or chronic kidney disease from all causes, including diabetes.

"The use of that category of drugs in patients with kidney disease can make all sorts of problems worse," Falk said. "It can raise blood pressure, make anti-hypertensive drugs less effective, cause fluid retention and worsen kidney function. We would like other treatments, such as acetaminophen, considered first in patients with chronic kidney disease."

Other organizations releasing lists Wednesday are the American Academy of Family Physicians, American College of Physicians, American Gastroenterological Association, and American Society of Nuclear Cardiology. Eight additional specialty societies will release lists in the fall.

Deborah L. Shelton and Julie Deardorff write for the Chicago Tribune.