April 4, 2012 — A man sees a physician after a simple fainting spell — should he receive a brain imaging scan when there is no evidence of seizures or other neurological signs and symptoms?
The answer is no, according to a compendium of 45 clinical "don'ts" assembled by 9 medical societies for the sake of eliminating commonly ordered but often unnecessary tests and procedures. Such services, which are not rooted in evidence-based medicine, contribute to the high cost of healthcare and sometimes harm a patient's health, as in excessive radiation exposure in the course of diagnostic imaging or complications of a surgery after a false-positive test result.
The lists of questionable services (5 for each specialty) are part of a campaign organized by the American Board of Internal Medicine (ABIM) Foundation called Choosing Wisely. It builds on a similar ABIM project last year that identified 5 dubious tests and procedures for 3 specialties: internal medicine, family medicine, and pediatrics.
The 9 medical societies participating in Choosing Wisely are the American Academy of Allergy, Asthma, and Immunology (AAAAI); the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians (ACP); the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology (ASCO); the American Society of Nephrology (ASN); and the American Society of Nuclear Cardiology.
"These societies have shown tremendous leadership in starting a long overdue and important conversation between physicians about what care is really needed," said ABIM President and Chief Executive Officer Christine Cassell, MD, in a news release.
The example of what not do to for a patient who fainted belongs to the list from the ACP. "In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms and signs," the ACP notes, "the likelihood of a central nervous system cause of the event is extremely low and patient outcomes are not improved with brain imaging studies."
The remaining ACP admonitions are as follows:
Do not order a stress test for asymptomatic patients who are at low risk for coronary heart disease.
Do not obtain imaging studies in patients with nonspecific low back pain.
Do not order imaging studies as an initial test for patients with low pretest probability of venous thromboembolism; instead, first obtain a high-sensitive D-dimer measurement.
Do not obtain a preoperative chest X-ray when lacking any clinical suspicion for intrathoracic pathology.
Diagnostic Imaging "Don'ts" Dominate
Not surprisingly, warnings against unnecessary diagnostic imaging also abound in the lists for the other specialties. ASCO, for example, cautions that physicians should not perform positron emission tomography, computed tomography, and radionuclide bone scans in the staging of early prostate cancer with a low risk for metastasis. ASCO explains that there is no evidence to suggest that such scans improve the detection of metastatic cancer or survival.
One item in the list from the AAAAI encourages, rather than discourages, testing. It advises physicians not to diagnose or manage asthma without spirometry. Basing the diagnosis merely on symptoms is problematic, because the symptoms may stem from causes other than asthma, according to the AAAAI.
Most of the 45 questionable services involve some form of testing. In contrast, 4 of the 5 "don'ts" compiled by the ASN alert physicians to treatment mistakes. One example is, "Avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure or chronic kidney disease from all causes, including diabetes." Another one from ASN is nontechnical in nature: "Don't initiate chronic dialysis without ensuring a shared decision-making process between patients, their families and their physicians."
Helping lead the Choose Wisely campaign is the watchdog organization Consumer Reports. It will work with other consumer-oriented groups such as AARP, the Leapfrog Group, and Wikipedia to educate patients about the lists of wasteful services. Presumably, an informed patient might question a physician's recommendation for a brain scan after a simple fainting spell. However, the Choosing Wisely campaign acknowledges that patients themselves often request unnecessary tests and treatments.
More information on Choosing Wisely is available on the initiative's Web site.
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