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April 25, 2012

Choosing Wisely: Associations Join to Educate Physicians and Pateints on Unnecessary Tests and Treatments

Choosing Wisely

A recent initiative lead by the American Board of Internal Medicine Foundation (ABIM Foundation) and in partnership with Consumer Reports, aims at reducing unnecessary medical treatment, which some estimate constitutes one-third of medical spending in the U.S.  This includes unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.  Some claim that doctors perform 45 common tests and procedures less often. 

The initiative, called Choosing Wiselyurges patients to question these services if they are offered.  The initiative has garnered 9 professional medical specialty partners with 8 others preparing to follow.  These partners include: 

These specialty societies represent 374,000 physicians.  Each society has developed a list of "Five Things Physicians and Patients Should Question" which patients can access from the website.   Additionally, eight new specialty societies have joined the campaign and will be releasing lists in fall 2012: 

A recent article in the Journal of the American Medical Association (JAMA), also discussed the new initiative.  The article explained how the origins of this campaign are from the “Medical Professionalism in the New Millennium: A Physician Charter.”  Authored in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine, the charter has as its fundamental principles the primacy of patient welfare, patient autonomy, and social justice. 

It articulates the professional responsibilities of physicians, including a commitment to improving quality and access to care, advocating for a just and cost-effective distribution of finite resources, and maintaining trust by managing conflicts of interest.  The charter's commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures. 

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative.  “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

“Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters.  But their change of heart also reflects recent changes in the health care marketplace.” 

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches.  The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes.  In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. 

“With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.” 

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation. 

“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder.  “This kind of one-size-fits-all approach can be a real detriment to good care.”

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.” 

“By identifying tests and procedures that might warrant additional conversations between doctors and patients, we are able to help patients receive better care through easy-to-use and accessible information,” said James A. Guest, J.D., president and CEO of Consumer Reports. “We’re looking forward to being a part of this innovative effort working with the ABIM Foundation, the specialty societies, and our eleven consumer communications collaborators to get this important message out to diverse populations of patients.”

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