Just say don't: Doctors question routine tests and treatments

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Thursday, February 21, 2013

EKG technician Diana Goodie (R) performs an electrocardiogram on a patient in the hallway of the emergency room at Ben Taub General Hospital in Houston, Texas, July 27, 2009. REUTERS/Jessica Rinaldi

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By Sharon Begley
NEW YORK (Reuters) - Now there are 135.
That's how many medical tests, treatments and other procedures - many used for decades - physicians have now identified as almost always unnecessary and often harmful, and which doctors and patients should therefore avoid or at least seriously question.
The lists of procedures, released on Thursday by the professional societies of 17 medical specialties ranging from neurology and ophthalmology to thoracic surgery, are part of a campaign called Choosing Wisely. Organized by the American Board of Internal Medicine's foundation, it aims to get doctors to stop performing useless procedures and spread the word to patients that some don't help and might hurt.
"Americans' view of healthcare is that more is better," said Dr Glenn Stream, a family physician in Spokane, Washington, and board chairman of the American Academy of Family Physicians, which has identified 10 unnecessary procedures. "But there are a lot of things that are done frequently but don't contribute to people's health and may be harmful."
In a particular case, even a procedure that provides no benefit to the vast majority of people might be appropriate. That's why the physicians emphasize that they are only advising against routine use of the usually unnecessary tests and therapies.
For instance, the American Academy of Pediatrics says physicians "should question" CT scans for kids' minor head injuries or abdominal pains, which usually don't improve diagnoses and raise the risk of cancer. But if doctors suspect something unusual, a scan may be in order.
For the most part, the medical specialty groups did not consider cost when they made their lists. If their advice is followed, however, it would save billions of dollars a year in wasteful spending, said Dr John Santa, director of Consumer Reports' Health Ratings Center and a partner in Choosing Wisely.
One large medical group with 300,000 patients, Santa said, calculated that following the Choosing Wisely advice on just two procedures, superfluous EKGs (electrocardiograms) and bone-density scans, would reduce its billings by $1 million a year. Nationally, that translates into some $1 billion in savings.
The medical specialty groups each came up with five procedures to "question," but most of the items begin with an emphatic "don't." The targeted procedures range from the common to the esoteric.
RETHINKING SWIMMER'S EAR, PRE-OP TESTS
Other specialists say no cough and cold medications for kids under 4, no oral antibiotics for acute infections of the ear canal ("swimmer's ear") and no use of drugs to keep blood sugar in older adults with type 2 diabetes within tight limits. There is no evidence that tight "glycemic control" - which is widely practiced - is beneficial, said the American Geriatrics Society. Instead, the diabetes drugs used to achieve tight control increase mortality, and tight control itself can cause low blood sugar.
Some recommendations, if widely adopted, would mean significant changes in patient care. The geriatricians, for example, recommend against feeding tubes in patients with advanced dementia. The tubes hurt and cause problems; carefully feeding the patient is better.
Anyone who has ever had surgery while in generally good health can sympathize with the recommendation against multiple pre-op tests: Ophthalmologists now advise against EKGs and blood glucose measurements before eye surgery, except for patients with heart disease or diabetes.
Physicians recommend against many procedures patients have come to expect, including imaging for low back pain (unless it has lasted more than six weeks) and any cardiac screening, including EKGs, in patients without heart symptoms.
The widely used "DEXA" X-ray screening for osteoporosis landed in rheumatologists' crosshairs. It should not be done more than once every two years, they advise, because changes in bone density over shorter periods are typically less than the machines' measurement error, which can cause women to think they're losing bone mass when they're not.
RETREAT FROM DEFCON
Other "don't's" may be hard sells to patients for whom any abnormality requires medicine's version of Defcon 1.
Take a finding of abnormal cells in the cervix. The American College of Obstetricians and Gynecologists (ACOG) says not to treat women whose Pap test for cervical cancer finds dysplasia unless the abnormalities persist for two years.
"Treatment damages the cervix and raises the risk in subsequent pregnancies," said ACOG Executive Vice President Dr Hal Lawrence. The abnormal cells are almost always the result of a viral infection that the body clears on its own, but women who think they mean impending cervical cancer will need convincing.
If doctors adopt the recommendations of their specialty, doctor visits for some chronic diseases would be very different. Patients with recurrent headaches would not get EEGs (electroencephalography); they don't improve outcomes. And rheumatologists would not use MRIs to monitor joints in patients with rheumatoid arthritis; a clinical assessment is just as good.
Women in particular would get quite different care. Those younger than 21 and those who have had a hysterectomy for anything but cancer should not get Pap smears at all, experts say. Other women should get the tests every three years, not annually, between ages 30 to 65.
"We did a great job training everyone, women as well as doctors, to get an annual Pap smear," said ACOG's Lawrence. "Now we have to untrain them."
That won't be easy. The first Choosing Wisely list of 45 procedures was released last April, too recently for there to be hard data on whether they're changing practice. But some of these battles have been fought for years, with scant success.
ACOG has been trying to reduce the rate of elective cesareans for decades, and its Choosing Wisely list tells obstetricians not to schedule elective cesareans or induce labor before week 39. The rate of cesareans in the United States was 33 percent of deliveries in 2009, up from 21 percent in 1996, federal data show.
WORSE FOR BABIES, BETTER FOR REVENUES
The experience of Intermountain Healthcare, a group of hospitals and clinics in Utah, suggests why. The nonprofit recently cut its rate of inappropriate labor inductions and cesareans from 28 percent of births to 2 percent. That saved Utah $50 million a year in healthcare spending, mostly by reducing use of the neonatal intensive care unit, where many babies delivered in these ways wind up. But Intermountain also lost $9 million in annual billings.
"In our fee-for-service healthcare system," said Consumer Reports' Santa, "poor clinical outcomes for babies improve revenue streams for hospitals," and better care can reduce revenues.
Many business groups have signed on to Choosing Wisely, hoping it will reduce soaring healthcare costs. For instance, the National Business Coalition on Health, with 7,000 employer members, and the National Business Group on Health, representing Fortune 500 companies and other large employers, are distributing to their members educational material developed by Consumer Reports, a partner in Choosing Wisely.
They are careful to emphasize that the advice comes from doctors. "If employers say you shouldn't have all these tests or procedures, it'll inevitably be seen as 'my employer doesn't want to spend the money to cover them,'" said Helen Darling, president of the Business Group.
The pages and pages of lists raise an obvious question: How did so many worthless and even dangerous procedures become so widely used?
For one thing, there is no regulatory requirement that physicians prove a new procedure helps patients, as drug makers must do before selling a new pharmaceutical.
For another, "Americans want the latest, newest thing," said Dr Howard Brody of the University of Texas Medical Branch, whose 2010 challenge to physicians to identify worthless tests and treatments inspired Choosing Wisely. "Technological enthusiasm on the part of physicians and the general public makes them willing to adopt new things without rigorous testing. Only years later, and only if studies are done, do we see that it's no good."
(This version of the story was corrected to say National Business Coalition on Health from National Business Council on Health in the fifth paragraph from the bottom.)
(Reporting by Sharon Begley; Editing by Jilian Mincer and Prudence Crowther; Desking by Vicki Allen)

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