Archive | April 2012

“Choosing Wisely”: Reduce Unneeded Tests and Procedures

The Choosing Wisely® campaign brings together nine medical societies to call attention to overused and often unnecessary tests and procedures.

From the official description:

“Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:

Supported by evidence
Not duplicative of other tests or procedures already received
Free from harm
Truly necessary”

Each society listed five tests or procedures to be carefully considered before helping patients choose their care.

The experts behind this effort know all about unnecessary testing.

Many physicians were taken aback by the irony of these organizations seeking to halt unneeded clinical tests while requiring already board-certified physicians to maintain their certifications with frequent tests (and fees).  Maintenance of Certification is not evidence-based, and has not been shown to benefit patients.  Concurrently, these organizations have helped to reduce residency work hours and expanded the practice domain of non-physicians.

One can imagine what Osler or Halsted might think of these developments.

Without question, there are a large number of procedures and tests that are not necessary, and are overused for a variety of reasons, roughly categorized as follows:

Knowledge gap (unsure of diagnosis)
Patient or family demand
Some form of physician self-interest (defensive medicine, revenue, community referral)

Most of the recommendations are straightforward, and controversial subjects such as age of mammogram screening and prostate testing are avoided.  Some overlap, such as back pain imaging and not treating colds with antibiotics.

My specialty (plastic surgery) is absent, perhaps because much of the field is now focused on non-medically necessary services anyhow.  That is meant in jest, but I offer one plastic surgery recommendation that makes sense and fits the theme:

“Do not order facial imaging studies for uncomplicated lacerations without clinical evidence or suspicion for fracture.”

Most of these studies do not help.  They are mainly for defensive-medicine purposes, and therefore cannot always be omitted

Getting back to the main list of procedures, I was pleased to see the radiology list included this:

“Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.”

I wrote about this before, and it’s a good thing to avoid unneeded radiation in kids, and reserve CT as a second-line test.

The need for campaigns about unnecessary testing and procedures is not surprising given our non-market based healthcare system.  It has oddly structured incentives, information asymmetry (which is leveling every day), and legal pitfalls; good care but a bad outcome can result in a lawsuit.

When patients do not pay directly for care, and physicians are trained not to consider cost, and are subject to legal risks, it is no surprise that overuse occurs.  As we transition much of healthcare toward a more protocol-driven model, such lists will be refined and expanded.  Backed by good science, they may improve care while reducing costs.

Challenges include managing patient expectations, and providing legal cover for care that follows recommendations but results in a delay in diagnosis.