Heeding advice on primary care "don'ts" would save $6.7 billion annually

Steering clear of brand-name statins accounts for most of the projected savings. Researchers hope other specialties will follow suit in identifying unnecessary interventions.

By Kevin B. O’Reilly — Posted Oct. 19, 2011

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Internists, family physicians and pediatricians could help slash nearly $7 billion in annual health spending by avoiding the top-five commonly ordered, low-evidence interventions in each of their specialties.

Nearly 90% of the primary care "don't" savings, or $5.8 billion, would come from prescribing generic, rather than brand-name, statins when starting lipid-lowering therapy, according to research published online Oct. 1 in Archives of Internal Medicine (link).

A 15-physician panel called the Good Stewardship Working Group compiled top-five "don't" lists of interventions they say are wasteful because evidence for their effectiveness is lacking. The lists, published online May 23 in Archives of Internal Medicine, target areas such as imaging for short-term low back pain with no other symptoms; ordering blood chemistry panels or urinalyses for screening in healthy adults; and prescribing antibiotics for sinusitis (link).

Researchers looked at data from the 2009 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to see how often each intervention was ordered inappropriately and tallied the direct costs linked to them.

Cutting out back-pain imaging would save $175.4 million annually, and slashing routine lab studies would save $32.7 million. Stopping unneeded antibiotic prescribing would reduce spending by an additional $116.4 million. Avoiding bone density scans in female patients younger than 40 would cut $527.4 million more in health spending.

The $6.7 billion total in estimated primary-care savings represents a sliver of the $750 billion in avoidable spending across all areas of care that a 2010 Institute of Medicine panel said was due to unnecessary services, inefficient delivery, high prices, bureaucracy, fraud and a lack of preventive care. Targeting "don'ts" in primary care is the beginning of a larger project to cut back on unneeded care, said Minal S. Kale, MD, lead author of the Oct. 1 Archives report.

"Primary care is a cognitive field, so we don't have a lot of costly procedures that we do as a group of physicians," said Dr. Kale, a general internal medicine fellow at Mount Sinai Medical Center in New York. "But this could prompt other physicians who are specialists, or who have costly procedures they are in control of, to reveal whether those procedures and tests are necessary and benefit patients. Even though this is a relatively small sum, it's still important that we've started the process."

Letterman's inspiration

Several national medical specialty societies are developing top-five "don't" lists in their care areas, said Stephen R. Smith, MD, MPH, principal investigator of the Good Stewardship Working Group, which was convened by the National Physicians Alliance, an organization for liberal physicians.

"This is a concept people can easily get their mind around," said Dr. Smith, who patterned the top-five idea after David Letterman's nightly top-10 lists. "It really doesn't matter what those top five are. Any physician in any specialty could come up with a top-five list. The point is to change the culture to make physicians more sensitive to their role in delivering high-quality care that can also constrain costs."

A grant from the American Board of Internal Medicine Foundation is funding a series of videos to educate physicians and patients about the top-five "don't" lists, said Dr. Smith, professor emeritus of family medicine at the Warren Alpert Medical School of Brown University in Rhode Island.

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