'Choose Wisely' Project Lists Overused Tests
Nine specialty groups have listed tests and treatments that are frequently overused, such as CT scans for low back pain and antibiotics for sinus attacks, as part of a project organized by the American Board of Internal Medicine (ABIM) and promoted by Consumer Reports.
Called "Choose Wisely," the project is aimed at encouraging patients as well as physicians to follow evidence-based guidelines in managing health problems, avoiding medical procedures that are unlikely to be of real help.
Each of the nine societies compiled a list of "Five Things Physicians and Patients Should Question," focusing on tests, drug therapies, and procedures that they viewed as often ordered without consideration of risks and costs relative to the benefits.
In a Viewpoint article published online in the Journal of the American Medical Association, two officials of the ABIM and Consumer Reports said the effort is aimed at reducing waste and needless harm in the healthcare system.
"The hope is that the lists will spark discussion between clinicians and patients about the need -- or lack thereof -- for many frequently ordered tests or treatments," wrote ABIM President Christine Cassel, MD, and James Guest, JD, president of Consumer Reports.
The nine societies joining the first prong of the project are the American College of Radiology (ACR), the American College of Physicians (ACP), the American Academy of Allergy, Asthma, and Immunology (AAAAI), the American Academy of Family Physicians, the American College of Cardiology, the American Gastroenterological Association (AGA), the American Society of Clinical Oncology (ASCO), the American Society of Nephrology (ASN), and the American Society of Nuclear Cardiology (ASNC).
Eight additional societies have also joined the effort, with their "top five" lists to be released in the fall of 2012.
For the first nine organizations, diagnostic tests dominated their lists.
Number one on the American College of Radiology's (ACR) list, for example, was imaging studies for uncomplicated headache. In patients without "specific risk factors for structural disease," the group said, such testing was unlikely to alter management or increase the chances of treatment success.
The top item for the American College of Physicians (ACP) was routine screening of low-risk, healthy-seeming people with exercise ECG tests. "In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%), screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes," the group indicated.
The first questionable tests or treatment listed by the seven other groups were as follows:
- AAAAI: IgG testing and indiscriminate IgE batteries for diagnosing allergies
- AAFP: imaging for low back pain during the first six weeks in the absence of "red flags" indicating neurological involvement
- ACC: stress cardiac imaging or other advanced noninvasive imaging in asymptomatic patients or those at low risk for coronary disease
- AGA: long-term acid suppression for gastroesophageal reflux disease without attempting dosage reductions
- ASCO: Cancer-directed therapies for solid tumor cancers in very ill, poor-prognosis patients
- ASN: Routine cancer screening in patients on chronic dialysis with limited life expectancies and without specific symptoms suggestive of cancer
- ASNC: Stress cardiac imaging and coronary angiography in asymptomatic or low-risk patients
Also duplicated on several lists was the use of chest imaging for preoperative cardiac risk assessment in low-risk patients undergoing noncardiac surgery.
In fact, overuse of imaging was a common theme in the project, with 8 of the 9 societies listing at least one imaging-related test. Of the 45 items overall, 24 specifically involved imaging.
But although most of the questionable procedures were diagnostic tests, frequently needless therapies shared the spotlight.
The ASN, for example, yellow-flagged four treatments: nonsteroidal anti-inflammatory drugs in patients with comorbidities predisposing them to complications from the drugs; erythropoiesis-stimulating drugs in patients with mild to moderate anemia; use of peripherally placed central catheters instead of arteriovenous fistulas for dialysis access; and starting dialysis without a careful, informed decision-making process with patients and their families.
The ACC took a dim view of stenting non-culprit lesions during PCI procedures in patients with uncomplicated, hemodynamically stable ST-elevation MI, and ASCO was skeptical of colony-stimulating factor drugs for preventing febrile neutropenia in low-risk patients.
The Choose Wisely project is the latest in a growing, physician-led movement to focus on medical procedures that clearly deliver more benefit than harm.
The Archives of Internal Medicine, for example, has published a series of articles under the heading "Less is More." Cassel and Guest also pointed to lists developed by the National Physicians Alliance to help primary care physicians avoid unnecessary tests and treatments.
The next eight professional societies promising to develop "top five" lists in the Choose Wisely project, according to the ABIM, are:
- American Academy of Hospice and Palliative Medicine
- American Academy of Otolaryngology–Head and Neck Surgery
- American College of Rheumatology
- American Geriatrics Society
- American Society for Clinical Pathology
- American Society of Echocardiography
- Society of Hospital Medicine
- Society of Nuclear Medicine
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