ACP drafts list of 37 commonly misused screenings and tests

Physicians are encouraged to stop ordering tests for nonspecific low back pain and MRIs as the breast cancer screen of choice in average-risk women.

By Christine S. Moyer — Posted Feb. 6, 2012

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When a patient asks for a screening or diagnostic test, physicians should take a moment to ask themselves whether the results will change how they care for him or her, says the editor of Annals of Internal Medicine.

"If the answer is no, then there is probably little reason to order it," Annals Editor Christine Laine, MD, MPH, wrote in an editorial in the Jan. 17 issue of the journal.

Too often, doctors order tests without stopping to think whether the patient recently received it elsewhere and whether conducting the tests would help the patient, Dr. Laine said.

Her comments were prompted by an American College of Physicians report published in the same issue of Annals. The article detailed a list of 37 common clinical situations in which screening and diagnostic tests provide little or no benefit.

Those situations include performing imaging studies on patients with nonspecific low back pain, screening low-risk individuals for hepatitis B virus infection and using an MRI as the breast cancer screening test of choice in average-risk women.

The list was completed in 2011 by a work group of 11 internists who are ACP members.

The organization is encouraging physicians and other health professionals to offer feedback by completing a Web survey on the journal's website. Survey respondents can indicate clinical situations they think should be added to the list or omitted from it.

Steven Weinberger, MD, who co-wrote the article on the 37 clinical situations, said the ACP already has received hundreds of comments, most of them positive.

"One of the goals was to stimulate a dialogue with other physicians to get a sense from them about other areas we might have missed or could have been included," said Dr. Weinberger, executive vice president and CEO of ACP. "We want to change [physician] behavior and, as a result, improve patient care. Our goal really is to provide the right care for patients at the right time. Not too much and not too little."

The ACP also hopes its list helps reduce health care costs by eliminating spending on testing that is often unnecessary. The report states that annual U.S. health care spending increased from $253 billion in 1980 to more than $2.2 trillion in 2008. Driving that uptick are new drugs, devices, procedures and tests, according to the report's authors.

They said the true expense of a test includes not only the cost of the screen but also expenses incurred because it was performed. For example, an exercise stress test in an asymptomatic patient might result in a false-positive finding that leads to cardiac catheterization, with its attendant costs and risks but with no proven benefit, the report said.

Steps toward improving patient care

The ACP work group identified commonly used tests in internal medicine that the panelists thought were unlikely to be of high value. If everyone in the group agreed, the test was added to the list.

The ACP's definition of high-value care stipulates that the health benefits of an intervention justify its harms and costs. Such harms of testing can include exposure to elevated levels of radiation, heightened patient anxiety and complications from unnecessary procedures, the study authors said.

The doctors discussed suggestions that received support from at least two-thirds of the group but fell short of unanimous approval. After discussion, proposed tests were added to the list if everyone agreed the tests do not reflect high-value care. The other suggestions were omitted from the collection of clinical situations.

Baltimore internist Zackary Berger, MD, PhD, agrees with the ACP's list and thinks it will help physicians determine when they should conduct screening or diagnostic tests, particularly in instances when patients request them. He said such patient demands are among the reasons doctors sometimes improperly use tests, because it often takes more time to explain why one is not needed than to order it.

Other factors in ordering tests include incentives to do more procedures and tests because of payment and physicians' natural inclination to want to know the cause of a health problem, said Dr. Berger, assistant professor in the division of general internal medicine at Johns Hopkins University School of Medicine in Baltimore.

"It's going to take more than [the ACP] article to change the practice of medicine," he said. "But I think the list is more than a start. It's a great step" toward improving patient care.

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Tests that may be overused

The American College of Physicians convened a work group of internists to identify common screening and diagnostic tests in internal medicine that may be overused. Among those tests were:

  • Annual lipid screening for patients not receiving lipid-lowering drugs or diet therapy to determine the reason for changing lipid profiles.
  • Using magnetic resonance imaging rather than mammography as the breast cancer screening test of choice for average-risk women.
  • Screening low-risk people for hepatitis B virus infection.
  • Cervical cancer screening in low-risk women 65 or older and in those who had a total hysterectomy for benign disease.
  • Testing for colorectal cancer in adults older than 75 or with a life expectancy of less than 10 years.
  • Prostate cancer screening in men older than 75 or with a life expectancy of less than 10 years.
  • Imaging studies in patients with nonspecific low back pain.
  • Serologic testing for suspected early Lyme disease.
  • Antinuclear antibody test in patients with nonspecific symptoms, including fatigue and myalgia or in patients with fibromyalgia.

Source: "Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care," Annals of Internal Medicine, Jan. 17 (link)

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External links

"Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care," Annals of Internal Medicine, Jan. 17 (link)

"High-Value Testing Begins With a Few Simple Questions," Annals of Internal Medicine, Jan. 17 (link)

"Survey: Which testing scenarios are low-value?" Annals of Internal Medicine, Jan. 17 (link)

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