Medical societies list 45 dubious tests, therapies

April 04, 2012

Washington, DC - A man undergoing PCI with stenting for an acute MI is found to have other stenoses in arteries unrelated to the site of his infarction. Should those other lesions be stented as well?

The answer is no, according to a compendium of 45 clinical "don'ts" assembled by nine medical societies, including the American College of Cardiology (ACC), for the sake of eliminating commonly ordered but often unnecessary tests and procedures. Such services, 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 surgery following a false-positive diagnosis.

The lists of questionable services—five for each specialty—are part of a campaign organized by the American Board of Internal Medicine (ABIM) called Choosing Wisely[1]. It builds on a similar ABIM project carried out last year that identified five dubious tests and procedures in three specialties: internal medicine, family medicine, and pediatrics.

The eight other medical societies participating in Choosing Wisely are the American Academy of Allergy, Asthma & Immunology, American Academy of Family Physicians, American College of Physicians, American College of Radiology, American Gastroenterological Association, American Society of Clinical Oncology (ASCO), American Society of Nephrology (ASN), and 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," commented ABIM president and chief executive officer Dr Christine Cassell (Philadelphia, PA) in a press release.

ACC's list reflects recent controversies

The example of what not do to for a patient with non-infarct-related lesions is part of the list from the ACC. "Patients experiencing a heart attack and undergoing a procedure called percutaneous coronary intervention (PCI) should not have stents placed in an artery or arteries beyond those responsible for the heart attack," the ACC notes.

Indeed, all five "don'ts" on the ACC's list speak to the mounting controversy over the use of certain procedures and imaging tests and a renewed emphasis on "appropriateness criteria." But although appropriateness documents have been geared toward physician practices, the Choosing Wisely campaign has a more sweeping aim—that of sparking "important conversations" between physicians and patients, as well as "other healthcare stakeholders" about the rationale for a given test or procedure.

The remaining ACC admonitions are all related to cardiac imaging:

  1. Cardiac imaging tests (particularly stress tests or advanced noninvasive imaging) should not be given if there are no symptoms of heart disease or if high-risk factors such as diabetes or peripheral arterial disease (PAD) are not present.

  2. Cardiac imaging tests (particularly stress tests or advanced noninvasive imaging) should not be given as part of routine annual follow-up in patients who have had no change in signs or symptoms.

  3. Cardiac imaging tests (particularly stress tests or advanced noninvasive imaging) should not be given prior to performing low-risk surgery that is not related to heart disease.

  4. Echocardiography, which uses sound waves to create images of the heart, should not be used as routine follow-up care in adults with mild heart-valve disease who have had no change in signs or symptoms.

Diagnostic imaging "don'ts" dominate

Not surprisingly, warnings against unnecessary diagnostic imaging also abound on the lists of other specialties. ASCO, for example, cautions that physicians should not perform positron-emission tomography, computed tomography, or radionuclide bone scans in the staging of early prostate cancer with a low risk of metastasis.

Most of the 45 dubious services involve some form of testing. In contrast, four of the five "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."

The watchdog organization Consumer s Union is helping lead the Choosing Wisely campaign. It will work with other consumer-oriented groups, such as AARP, 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.

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