New Prescription for Better Health Care: Less Is More
A groundbreaking campaign urges physicians to quit ordering 135 unnecessary tests and procedures
When your physician recommends you undergo a battery of tests, even if you're not feeling ill, are you comforted or skeptical? Either way, most of us trust that our doctors are making the right decisions for our care and so, even if the tests seem onerous, we usually go along.
But now a new campaign seeks to empower patients and change that conversation. Choosing Wisely, launched in 2012 by the ABIM Foundation, has brought together the leaders of 26 physician societies representing more than 350,000 American doctors to do something many patients may find shocking: recommend that we get less medical care.
"It's an act of professionalism," says Daniel Wolfson, chief operating officer of the foundation. "Physicians groups are standing up to say here's the right thing to do in these circumstances. They've been quite courageous and bold."
Each participating physicians group has identified five common tests and procedures that may be overused, unnecessary or potentially harmful to patients. There are already 135 such guidelines posted on Choosing Wisely's website. By the end of the year, Wolfson expects to have more than 200 recommendations, from 40 doctors' groups. Another, patient-focused version of the list, using less technical language, can be found at consumerhealthchoices.org, a free site produced by the board's partner Consumer Reports, which also offers practical advice for raising questions with your physicians.
The underlying message: When it comes to medical care, "less is sometimes better," Wolfson says. The campaign is intended to launch informed conversations between doctors and patients that will improve the quality and safety of health care and re-emphasize the physicians' mantra of "do no harm."
"We don't want to put patients at risk for procedures and tests that have little or no benefit," Wolfson says, adding that none of the recommendations should be considered an absolute. "In some cases, you might need these tests." (The Consumer Reports site explains when certain tests might have value.)
Limiting unnecessary procedures across the system, of course, could have a major impact on health care costs. But Wolfson says that's not the campaign's primary goal. "In most situations the byproduct is lower costs," he says, "but there are some things on the list that would actually increase costs. We're only trying to enhance appropriate care."
Still, it's easy to see how savings could accumulate when Choosing Wisely's guidance is put into practice. "Sometimes one test leads to downstream tests," Wolfson points out.
For example, a questionable result on a cardiac stress test in an asymptomatic patient often leads a doctor to order cardiac catheterization, "which is not only unnecessary but could be harmful," Wolfson says. "You've got to think about the risks, benefits and costs of those downstream procedures."
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The ABIM Foundation is aware, though, that patients are often as much to blame as their doctors for unnecessary procedures. "We want to convince both patients and physicians that less is sometimes better," Wolfson says. Too often, he says, we seek multiple opinions and demand new tests or scans that we've heard about from friends, relatives and the media, even though there is little evidence that they would do us any good.
"Every new technology is not always better," Wolfson says. "As Americans, we're hooked on technology — and not always with the accompanying evidence that it makes a difference. When patients know what is necessary and what's not, they can be less demanding."
Prescriptions and Screenings That Should Raise Red Flags
Some of the campaign's recommendations echo well-known guidelines, but others call out concerns with certain procedures that the public may not yet be aware of. The Society of Nuclear Medicine and Molecular Imaging, for example, now discourages members from ordering routine annual stress tests after coronary artery surgery. The reason: The nuclear heart scan has limited usefulness and exposes patients to radiation equivalent to about 2,000 chest X-rays.
Family caregivers may find the guidelines especially informative. On its list, the American Geriatrics Society advises against using feeding tubes in patients with advanced dementia. Instead it prescribes that they be fed orally, to limit agitation, the use of restraints and pressure ulcers. And the American Academy of Hospice and Palliative Medicine discourages doctors from delaying palliative care techniques for seriously ill patients, even if they're already receiving aggressive treatment for their disease. The group's conclusion is based on evidence that the introduction of palliative care does not accelerate death, but relieves pain and limits overall costs.
(MORE: How We All Benefit From Palliative Care)
Several items focus on common drugs. The campaign discourages doctors from prescribing sedative hypnotics, or benzodiazepines like Valium, to manage delirium, agitation or insomnia in older patients, given the escalated risk of accidents and falls. Similarly, the guidelines reject using opioids to treat migraines because in most cases frequent use of such drugs can actually worsen the condition. Doctors are also urged to avoid using medication to normalize blood glucose levels in Type 2 diabetes patients over age 65, which has been shown to contribute to higher mortality rates.
Additionally, physicians groups are using the Choosing Wisely platform as a vehicle to come out against the overuse of antibiotics, especially for illnesses like bronchitis that are caused by viruses, not bacteria.
A range of common scans come under fire in the Choosing Wisely campaign, including routine imaging for lower-back pain in the first six weeks of a complaint without specific warning signs, annual electrocardiograms (EKGs) for patients without risk factors and electroencephalography (EEG) scans for people complaining of frequent headaches. All are examples of tests the physicians groups now believe offer little clinical value. In the latter case, the American Academy of Neurology now states that EEGs have no advantage over clinical evaluations in diagnosing headaches, and simply increase costs.
Some recommendations may be controversial among some doctors and patients. For example, on its list, the American Society for Clinical Pathology advises against routine screening of low-risk patients for Vitamin D deficiency. The deficiency is common in many people, especially during winter months, the group says, and for most healthy patients, a combination of summer sun exposure and an over-the-counter supplement can satisfy Vitamin D requirements without the need for, or cost of, testing.
"This is all about cultural change," Wolfson says. "We want patients to go from asking, 'Why don't you do that test?' to 'Why did you do that test?' We are looking for those conversations to occur in the exam room at the local level. That's why we're doing this."