Sometimes, less health care is the best health care.
As part of an effort to help physicians curtail the practice of ordering unnecessary tests and procedures, the AAFP today released a list of five tests and treatments physicians should think twice about before performing, ordering or prescribing. The list is part of a national campaign called Choosing Wisely(www.ChoosingWisely.org) that launched at a press event here. The campaign is working to identify specific tests or procedures commonly used within various specialties that are not always necessary.
AAFP President Glen Stream, M.D., M.B.I., responds to a question during the April 4 Choosing Wisely news conference.
The Academy's involvement in the Choosing Wisely campaign underscores family physicians' long-term commitment to ensuring high-quality, cost-effective care to patients, said AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., in a prepared statement.
"Family medicine's 'top 5' list encourages more in-depth conversations between patients and their doctors so they discuss all options and then 'choose wisely' when it comes to a treatment plan," he said.
According to the Congressional Budget Office, as much as 30 percent of care provided in the United States consists of unnecessary tests, procedures, medical appointments, hospital stays and other services that may not improve people's health. CMS projects that if U.S. health care spending continues at current levels, it will reach $4.3 trillion, or 19.3 percent of the nation's gross domestic product, by 2019.
- AAFP has joined with eight other medical specialty societies in an effort to cut unnecessary health care spending.
- The nine organizations have created lists of tests and procedures physicians and patients should question.
- According to the Congressional Budget Office, as much as 30 percent of health care spending each year goes toward unnecessary tests and procedures.
In response, the Academy and eight other medical specialty societies -- the American Academy of Allergy, Asthma and Immunology; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology -- joined the Choosing Wisely campaign, which originated as an initiative of the American Board of Internal Medicine Foundation, last year.
The nine organizations initially participating in the Choosing Wisely campaign worked individually and collaboratively to create evidence-based lists of overused tests and treatments for their individual specialties. Dubbed "Five Things Physicians and Patients Should Question," the lists are designed to help physicians and patients think and talk about overuse or misuse of health care resources.
The AAFP's list consists of the following five recommendations:
- Do not do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.) Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs and involves unnecessary radiation exposure. Low back pain is the fifth most common reason for all physician visits.
- Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial clinical improvement. (Symptoms must include discolored nasal secretions and facial or dental tenderness when pressure is applied.) Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis, resulting in risk of side effects without benefit. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.
- Do not use dual-emission X-ray absorptiometry (DEXA) in women younger than age 65 or men younger than 70 with no risk factors. DEXA is not cost-effective in younger, low-risk patients but is cost-effective in older patients.
- Do not order electrocardiograms or other cardiac screening for low-risk patients without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.
- Do not perform Pap smears on women (who are) younger than 21 or who have had a hysterectomy for noncancer disease. Most observed abnormalities in adolescents regress spontaneously; therefore, Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for noncancer disease), and there is little evidence for improved outcomes.
The lists(choosingwisely.org) drawn up by the campaign's eight other medical specialty partners are available on the Choosing Wisely website. In addition, eight more medical specialty organizations signed on to the campaign during today's press event. They are scheduled to release their lists this fall.
Consumer Reports Health(consumerhealthchoices.org), a consumer partner in the Choosing Wisely campaign to identify tests or procedures commonly used within various specialties that are not always necessary, is leading the campaign's consumer communications program.
The company is providing resources for patients and physicians aimed at engaging them in conversations about appropriate use of health care resources. According to Consumer Reports President and CEO James Guest, the product-testing company is pushing the Choosing Wisely message to its members, as well as to other national consumer publications.
In an interview after the press event, Stream stressed the need to develop a solid, secure physician-patient relationship so meaningful patient conversations can take place.
"People really do need a doctor who knows them and can help them navigate the medical system if they have a serious medical problem," he told AAFP News Now. "It is also important to note that it is one thing to get a 'Choosing Wisely' decision from a doctor who knows you, but that to do that, you have to build trust up over time.
"I think that as family physicians, our role is unique, because we are not only managing the care that we give, but it is also just as critical that we coordinate care for our patients using our subspecialty colleagues."
Annals of Internal Medicine: "The 'Top 5' Lists in Primary Care: Meeting the Responsibility of Professionalism"(6 page PDF)
(Aug. 8/22, 2011)