This past week, nine medical organizations (American Academy of Allergy, Asthma & Immunology, American Academy of Family Physicians, American College of Cardiology, American College of Physicians, American College of Radiology, American Gastroenterological Association, American Society of Clinical Oncology, American Society of Nephrology, and the American Society of Nuclear Cardiology) along with business and consumer groups have started an effort to reduce costs and reduce patients’ exposures by minimizing the use of medical tests and treatments only when they are needed. Called Choosing Wisely, this is a project of ABIM Foundation (Advancing Medical Professionalism to Improve Health Care).
One of the efforts of the Choose Wisely campaign is having patients and physicians ask five questions. Nine United States specialty societies representing 374,000 physicians developed lists of "Five Things Physicians and Patients Should Question" in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures. These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation. For example, under Family Medicine, the list of five includes:
• Don’t perform a Pap smear on women younger than 21 or who have had a hysterectomy for non-cancer disease.
• Don’t order EKGs or any other cardiac screening for low-risk patients without symptoms.
• Don’t use dual –energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
• Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
• Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
Earlier this year, the American College of Physicians issued guidelines on 37 types of cases when physicians should think twice before ordering tests that maybe wasteful and possibly harmful to the patient. Annals of Internal Medicine
Also published this week, was another study on mammography, Annals of Internal Medicine, which, according to Harvard School of Public Health researchers along with those from Norway and Sweden, 15 to 25 % of invasive cancers detected via mammogram would never have turned life threatening. Further, screening afforded women only a slightly smaller risk of dying from breast cancer and didn’t appear to reduce the total number of deaths from any cause. So how often should breast screening be done using this technology?
The bottom line is that the medical profession is coming to terms with the fact that just because the technology is there, doesn’t mean it’s right for every patient all the time. That approach not only escalates health care spending, but it also posses real danger to the patient. Over testing and treating can be just as dangerous as not testing or treating. This is a scary situation for some people, particularly those who believe more is better and that the latest directives are “rationing” of healthcare.
The take home is that both patient and provider must have open dialogue about what makes sense for their particular situation. This requires patient and medical provider to educate themselves about testing and treatments and to discuss the pros and cons given the specifics of your situation.
The next time you see your provider, and there is a discussion about tests and treatments, consider the following questions: What is the purpose of doing the test? Are there any risks? What are the costs and does it provide significant information to warrant it? Does the outcome affect treatment options?
Several years ago, my son developed a very clear allergy to gluten. He went to the gastroenterologist, who performed a blood test for Celiac’s Disease. Needless to say, since he no longer eats gluten, it came back negative. The doctor offered two choices, do a biopsy to determine if it is Celiac’s or do nothing. Either way, since staying off gluten made him feel much better, the treatment would be the same. Doctor and patient both agreed that a biopsy didn’t make sense at this time.
The cost of testing and treatment is a factor that needs to be considered. Find out upfront what tests and treatments cost. Are there lower cost options? Are there behavior changes that can be tried? Can a generic prescription work as well as a name brand?
Ultimately, you have the right to refuse or request testing or treatments. A good discussion with your provider can help you make the best choice for you.
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