Primary care push to root out tests with low clinical value

Does your 85-year-old patient really need that colorectal cancer screening?

If a woman had a normal Pap smear last year, should the test be done again at the next yearly visit?

Is diagnostic imaging necessary for someone who has uncomplicated lower back pain?

Research and recommendations from the medical community have concluded that these tests aren’t necessarily the best courses of action for patients in those situations, resulting in low-value care if they are ordered. In a policy paper published online in Annals of Internal Medicine on Oct. 30, the American College of Physicians offered doctors recommendations on how they can use evidence-based performance measures to identify the strengths and limitations of tests and treatments to help weed out the ones that don’t benefit their patients — and that in some cases even may cause harm.

“Right now, physicians look at underuse of medicine in their practices, such as screenings for diabetics & but it is important to have measurements for overuse,” said David Baker, MD, MPH, an author of the study and chief of the Division of General Internal Medicine and Geriatrics at Northwestern University Feinberg School of Medicine in Chicago. “Physicians should take a leadership role in identifying these areas.”

Physicians should use performance measures that are based on high-quality evidence that assesses the risks, benefits, and costs of tests or treatments, the ACP study noted. But to develop performance measures for low-value services, data from other types of research and design methods also will be needed. For example, the study said subgroup analyses from clinical trials, cohort studies and cost-benefit analyses probably will need to be part of the evaluations.

Physician behavior in ordering tests or treatments can be changed through feedback to the doctors, public reporting, pay-for-performance programs and clinical decision support, the ACP report said (link).

An electronic health record system is one tool that gives doctors the opportunity to measure quality as well as a way to address the problems that are discovered, said Dr. Baker, who also is deputy director for the Institute for Public Health and Medicine at Feinberg.

“In the past year, we looked at our own practice to see how often we were doing Pap smears, and we didn’t look good,” he said. The data allowed his practice to recognize it was performing the test more often than necessary and to educate its physicians on national Pap smear guidelines.

Performance measures probably will need to be applied at a group level, such as for a multispecialty group practice or hospital, because individual physicians often don’t see enough patients to generate reliable data, the ACP study said.

The ACP noted that reducing the number of low-value tests and treatments is especially important considering the fact that health care spending is expected to reach nearly 20% of the nation’s gross domestic product by 2020. Some experts estimate that up to 30% of the $765 billion in annual health care costs potentially are avoidable. Many of the costs are attributed to inappropriate or unnecessary services, the ACP said.

“Physicians and patients need to work together to pursue care that improves health, avoids harms and eliminates wasteful practices,” said Amir Qaseem, MD, PhD, MHA, a study author and ACP’s director of clinical policy.

The paper follows the ACP’s launch of its High-Value, Cost-Conscious Care Initiative to help physicians and patients understand the benefits, harms and costs of interventions and determine whether services provide good value (link). The American Medical Association-convened Physician Consortium for Performance Improvement, a group of more than 170 health care organizations and individuals, also has addressed this issue (link).

In addition, the ABIM Foundation earlier in 2012 launched the Choosing Wisely campaign (link). It worked with nine physician specialty societies to identify tests and procedures whose necessity should be questioned and discussed. The campaign partnered with Consumer Reports to disseminate the information to patients, and more specialty societies are joining the campaign in 2013.