Most Wasteful Treatments, Procedures in Primary Care

May 23, 2011

May 23, 2011 — A study commissioned by a reform-minded medical society has come up with specialty-specific lists of procedures in primary care that do little if anything to improve outcomes but excel at wasting limited healthcare dollars.

A prime example is routinely ordering diagnostic imaging for patients with low back pain — but with no warning flags, such as severe or progressive neurologic deficits — within the first 6 weeks, according to the study, published online today in the Archives of Internal Medicine. The admonition to break this expensive bad habit appears in the top 5 list of treatment recommendations for both internal medicine and family medicine.

The top 5 recommendations for these 2 specialties as well as pediatrics consist mostly of "don'ts," such as the one for routine imaging for low back pain. There are 2 other "don'ts" that make both the internal medicine and the family medicine lists: Do not order dual-energy x-ray absorptiometry screening for women younger than 65 years or men younger than 70 years with no risk factors, and do not order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients.

The top 5 list for pediatricians includes recommendations to use inhaled corticosteroids to control asthma "appropriately" and not to prescribe antibiotics for pharyngitis unless a patient tests positive for streptococcus.

The authors, assembled by a group called the National Physicians Alliance (NPA), write that many routine treatments not only squander money but also expose patients to risks. False-positive results of cardiac testing, for example, "are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis."

The NPA, a 5-year-old organization with 20,000 members, seeks to make high-quality healthcare affordable to all. It calls itself a strong supporter of the new healthcare reform law called the Affordable Care Act.

Study Recommendations Validated by Practicing Physicians

The authors of the study belong to the Good Stewardship Working Group formed by the NPA. They drafted their lists with the aim of identifying treatment decisions that are common in primary care; are strongly supported by evidence; and are capable of improving health outcomes, reducing risk and harm, and decreasing costs.

They field-tested their initial choices with 83 primary care physicians, who agreed with all of them except for one in the family medicine list: Do not routinely order blood chemistry analysis for asymptomatic, healthy adults. That recommendation was replaced with one urging physicians not to routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for 7 or more days or worsen after initially improving.

The revised lists were then submitted to a second set of 172 physician field-testers, which gave strong support to them all.

Concern About Perception of Rationing

The NPA intends to share its top 5 treatment recommendations for the 3 primary care specialties with all its members. In addition, the group intends to produce training videos to help physicians discuss the guidelines with patients and gain their understanding and trust, lest patients think they are being denied needed care (a common scenario when they ask for antibiotics to treat a viral infection).

Another set of videos aimed at patients will explain how risks outweigh benefits with the treatments in question and how overutilization drives up insurance premiums.

The NPA also plans to seek the endorsement of its top 5 lists from consumer and patient safety groups, all with the goal of dispelling the notion that its advice represents "rationing."

"Often less is truly more," the authors write.

The study was funded by the American Board of Internal Medicine Foundation. The authors have disclosed no relevant financial relationships.

Arch Intern Med. Published online May 23, 2011. Abstract


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