Campaign to fight unneeded tests targets “more is better” mindset

The Choosing Wisely initiative rolls out 90 more examples of potentially unnecessary medical interventions to prompt wait-and-watch conversations between patients and doctors.

By — Posted March 4, 2013

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There are now 135 tests, procedures and other medical interventions that specialty societies are urging physicians to think twice about before ordering, as part of the American Board of Internal Medicine Foundation's Choosing Wisely initiative. The items were chosen based on evidence showing they are ineffective or unnecessary.

The campaign, launched with a list of 45 items in April 2012, also is stepping up its efforts to communicate a key message to patients, families and the public — in medicine, sometimes less is more. The widespread view that a physician who denies a test or treatment is offering substandard care puts pressure on doctors to order interventions against their better judgment, say the initiative's leaders.

“Our goal is nothing less than a culture shift, to teach Americans that more is not always better,” said Christine K. Cassel, MD, president and CEO of the ABIM Foundation. “This comes in the context of moving how physicians are paid, for the quality and the value of the care they provide rather than just more care. We want to foster a public environment that's welcoming of that kind of change.”

ABIM Foundation is partnering with Consumer Reports, which has covered the campaign's previous recommendations and worked with specialty societies to craft easy-to-understand patient education materials. A December 2012 Consumer Reports survey of adults who received information about the campaign found that 81% were likely to ask their doctors questions about one or more of the recommendations. The Wikipedia entries relating to the initial 45 items on the Choosing Wisely list have been viewed by 22 million Web users. Now ABIM Foundation will get a $2.5 million, 28-month grant from the Robert Wood Johnson Foundation to take the message to the local level through specialty societies and regional health collaboratives. (See correction)

“Reducing the overuse of health care resources is a critical part of improving the quality of health care in America,” said Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation. “We want to see what can happen when this work is targeted in specific geographic regions, and we are pleased to help increase the tangible impact of the Choosing Wisely campaign.”

Physician organizations representing more than 350,000 doctors specializing in family medicine, palliative care, neurology, ophthalmology, otolaryngology, pediatrics, obstetrics and gynecology, rheumatology, geriatrics, clinical pathology, echocardiography, urology, vascular medicine, cardiovascular computed tomography, hospital medicine, nuclear medicine and molecular imaging, and thoracic surgery each contributed lists of five medical interventions physicians and patients should question.

Wiser care choices sought

Elective deliveries before 39 weeks, routine annual Pap tests and stress tests in low-risk, asymptomatic patients are among the 90 items doctors and patients should think twice about, because the medical evidence links them to worse outcomes or false positives.

The American Academy of Hospice and Palliative Medicine says physicians should recommend oral assisted feeding, instead of feeding tubes, for patients with advanced dementia. The academy's list also urges deactivating implantable cardioverter-defibrillators when they are inconsistent with patient care goals. The society took care in crafting its list of five things to question, said Timothy E. Quill, MD, the academy's president.

“We don't want to be perceived as withholding any treatment or care,” he said. “In fact, helping people sort out what people want and don't want is part of our jobs.”

The ABIM Foundation has not done any work to estimate how much medical spending could be reduced if patients and physicians adhered to the Choosing Wisely initiative's recommendations on interventions to avoid.

Dr. Cassel and others involved with the initiative stressed that the recommendations should not be used to formulate payment policies, and that they are meant to start conversations among patients, physicians and families about the course of care. The focus of the five-things lists, however, is on interventions that are frequently done even though the best available medical evidence indicates that, at least in specific circumstances, they do not improve patient care or outcomes.

The American Medical Association has issued statements in support of the initiative, saying the campaign is consistent with the Association-convened Physician Consortium for Performance Improvement's effort to develop measures on overuse and inappropriate use.

Seventy-five more interventions to question will be released by 15 physician organizations later in 2013, the ABIM Foundation said.

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18 interventions primary care doctors should question or avoid

The medical specialty societies participating in the Choosing Wisely campaign have identified 90 more examples of potentially inappropriate care. Among them are items especially relevant to primary care physicians and their patients, which say:

  1. Don't schedule elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks' gestational age.
  2. Avoid elective, nonmedically indicated inductions of labor between 39 weeks and 41 weeks unless the cervix is deemed favorable.
  3. Don't screen for carotid artery stenosis in asymptomatic adult patients.
  4. Don't screen women older than 65 for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  5. Don't screen women younger than 30 for cervical cancer with human papillomavirus testing, alone or in combination with cytology.
  6. Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
  7. Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children younger than 4.
  8. CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation and Pediatric Emergency Care Applied Research Network criteria should be used to determine whether imaging is indicated.
  9. Neuroimaging is not necessary in a child with simple febrile seizure.
  10. Don't perform routine annual Pap tests in women 30 to 65.
  11. Don't treat patients who have mild dysplasia of less than two years in duration.
  12. Don't screen for ovarian cancer in asymptomatic women at average risk.
  13. CT scans are not necessary in the routine evaluation of abdominal pain.
  14. Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
  15. Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  16. Avoid using medications to achieve hemoglobin A1c of less than 7.5% in most adults 65 and older; moderate control is generally better.
  17. Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  18. Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Sources: Choosing Wisely lists of five things physicians and patients should question by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists and American Geriatrics Society

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External links

Choosing Wisely lists of five things to question, updated in February (link)

“Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care,” The Journal of the American Medical Association, May 2, 2012 (link)

“Medicine's ethical responsibility for health care reform — the Top Five list,” The New England Journal of Medicine, Jan. 28, 2010 (link)

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An earlier version of this story mischaracterized the Choosing Wisely campaign's Web traffic on Wikipedia. The sentence has been corrected. American Medical News regrets the error.

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