Choosing Wisely™

Your doctor recently ordered a medical test or course of treatment for you because (choose all that apply):

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1. She is practicing evidence-based medicine, i.e., the test or treatment has been proven effective in diagnosing/treating your condition
2. She is afraid she will be sued for malpractice if she misses something
3. She hasn't spent enough time with you
4. She is participating in quality measure reporting
5. All of the above

Answer: It depends...


According to an article by Brenda E. Sirovich, MD, MS, Steven Woloshin, MD, MS, and Lisa M. Schwartz, MD, MS, published last year in Archives of Internal Medicine, 42 percent of U.S. primary care physicians believe that patients in their own practices are receiving too much care; only 6 percent said they were receiving too little. Factors cited for aggressive testing and treatment included: fear of malpractice (76 percent); clinical performance measures (52 percent), and inadequate time spent with patients (40 percent). Sixty two percent said diagnostic testing would be reduced if not for financial incentives to specialists (39 percent for primary care physicians).

The cost of these unnecessary, and sometimes harmful, tests and treatments are estimated to be a third of the $2.6 trillion Americans spend on healthcare each year.

Last week, a new campaign that Dr. Donald Berwick—former Administrator of Centers for Medicare and Medicaid and longtime champion of patient safety—called "a game changer" was launched by nine prominent physician groups. The groups have each identified five specific tests or procedures that are commonly used but not always necessary. 

Choosing Wisely™ Five Things Physicians and Patients Should Question which is led by the American Board of Internal Medicine Foundation with Consumer Reports, includes such recommendations as:

• Don't order sinus computer tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis (American Academy of Allergy, Asthma & Immunology)
• For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals (American Gastroenterological Association)
• Don't do imaging for low back pain within the first six weeks, unless red flags are present (American Academy of Family Physicians)
• 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 (American College of Cardiology)
• Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology (American College of Physicians)

Full lists with rationales can be found on the Choosing Wisely™ website. Several more physician specialty groups are preparing lists that will be released in the fall of 2012.

While many in healthcare have praised the initiative, others worry that the recommendations may be adopted too broadly, restricting choice and putting patients at risk.

A press release for the campaign describes the lists as evidence-based recommendations that are meant to encourage discussion among physicians and patients and to guide decisions about the most appropriate care based on individual situations.

So the next time your doctor recommends a test or treatment, ask questions, talk through the options and together make the best decision for you.

References

Choosing Wisely by Christine K. Cassel, M.D. and James A. Guest, J.D. Journal of the American Medical Association, published online April 4, 2012.
Accessed at http://jama.ama-assn.org/content/early/2012/03/30/jama.2012.476.full

Doctor Panels Recommend Fewer Tests for Patients by Roni Caryn Rabin. The New York Times, April 4, 2012. Accessed at http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html

Physicians Wade Into Efforts To Curb Unnecessary Treatments by Julie Appleby. Kaiser Health News, April 4, 2012. Accessed at http://www.kaiserhealthnews.org/stories/2012/april/04/physicians-unnecessary-treatments.aspx

U.S. Physician Groups Identify Commonly Used Tests or Procedures They Say Are Often Not Necessary. Press release, April 4, 2012. Accessed at http://www.prnewswire.com/news-releases/us-physician-groups-identify-commonly-used-tests-or-procedures-they-say-are-often-not-necessary-146046345.html