Overcoming Overuse of Medical Practices

Healthcare provider associations come together to highlight costly and unnecessary practices

(RxWiki News) As rates of long-term disease and healthcare costs continue to soar in the United States, doctors and policymakers are looking for ways to boost health and lower costs. Cutting down on unneeded tests and treatments could help.

American specialty societies have come together to produce a series of lists of Five Things Physicians Should Question. These lists are intended to underline the importance of conversations between doctors and patients to improve care.

In addition, the lists highlight a number of tests, treatments and procedures that may be overused and unnecessary in many cases.

Based on scientific evidence, the lists offer recommendations on the topics doctors and patients should discuss in order to ensure that patients get the proper care they need based on their individual situations.

"Maintain an open conversation with your doctor."

The five-item lists were compiled as part of Choosing Wisely, an initiative of the ABIM Foundation. The societies that developed the lists represent more than 500,000 physicians.

In the Choosing Wisely lists, health experts call attention to medical interventions that may be helpful for some patients but not all. They cover tests, treatments and procedures involved in a variety of conditions - from allergies and asthma to cancer, heart disease and kidney disease. In addition, they address the care of people in specific demographics, such as the elderly and young children.

"Choosing Wisely is a thoughtful campaign to improve the quality of care while reducing its cost," said Adam C. Powell, PhD, Partner and President of Payer+Provider, a consulting firm which uses teams of economists, health services researchers, and physicians to provide precise answers to operational challenges faced by health insurance companies and hospitals.

"In 2008, the Image Gently campaign was launched to urge radiologists to carefully consider the intensity and quantity of imaging studies performed on children," Dr. Powell continued. "Testing can be reduced by carefully restricting the area of the body that is imaged, reducing the number of images taken, and avoiding duplicative testing. The Choosing Wisely guidelines for radiology keep with this theme."

In 2010, the United States spent nearly $2.6 trillion on health care - more than 10 times higher than the $256 billion spent in 1980. The increase in health spending is due to a variety of factors, most notably the price of technology and prescription drugs, the rise in chronic diseases and high administrative costs.

About half (51 percent) of the nation's health spending went to hospital care (31 percent) and doctor services (20 percent) in 2010. Another 10 percent was spent on retail prescription drugs.

One goal of the Choosing Wisely initiative is to get patients and doctors involved in the important conversation about the overuse of medical tests and procedures that aren't always beneficial and, in some cases, can cause harm.

For example, the list provided by the American Academy of Allergy, Asthma & Immunology (AAAAI) says, "Don't perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy." The usefulness of these tests in diagnosing allergy is still unproven. Instead, the AAAAI says that appropriate diagnosis of allergies requires specific IgE testing (testing of either the skin or blood) based on a patient's history.

"Appropriate diagnosis and treatment is both cost effective and essential for optimal patient care," the AAAAI suggests.

Another potentially unneeded intervention is highlighted by the American College of Obstetricians and Gynecologists. "Don't screen for ovarian cancer in asymptomatic women at average risk," the recommendation reads. In other words, don't screen for ovarian cancer in women without symptoms. 

There is not much evidence that screening women with no symptoms can detect ovarian cancer at an early stage. "Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits," according to the recommendation.

The American College of Radiology recommends against using imaging for uncomplicated headaches. 

The American Society of Nephrology recommends against performing routine cancer screening for dialysis patients with low life expectancies unless they have signs or symptoms of cancer. "An individualized approach to cancer screening incorporating patients' cancer risk factors, expected survival and transplant status is required," the recommendation reads.

The American College of Rheumatology says not to prescribe biologic drugs for rheumatoid arthritis before trying methotrexate or other conventional medications, such as non-biologic disease-modifying anti-rheumatic drugs (DMARDs).

And the recommendations go on and on.

The lists are not designed to totally eliminate the use of such tests, treatments and procedures. Rather, they are meant to encourage doctors and patients to evaluate whether they are needed. In other words, doctors and patients should discuss patients' individual situations in order to see if the benefits of the medical interventions can outweigh the costs.

"While there are clear savings in direct healthcare costs to utilizing fewer radiological tests, there are also indirect savings that are harder to measure," said Dr. Powell.

"Every time a person is exposed to radiation, it slightly increases their risk of developing cancer in the future. This risk is greater for children, as they have more years to live, and for people receiving more intense amounts of radiation," he said.

"By encouraging physicians to choose wisely, we can save both on the direct cost of the testing and on the future medical costs resulting from the potential damage caused by the testing," Dr. Powell concluded.

The lists are available on the Choosing Wisely website.

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Review Date: 
February 27, 2013