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Physicians Wade Into Efforts To Curb Unnecessary Treatments

Apr 04, 2012

Nine prominent physician groups today released lists of 45 common tests and treatments they say are often unnecessary and may even harm patients.

The move represents a high-profile effort by physicians to help reduce the extraordinary amount of unnecessary treatment, said to account for as much as a third of the $2.6 trillion Americans spend on health care each year.

Each of the societies, representing both primary care doctors and specialists, picked five procedures that medical evidence shows have little or no value for certain conditions, and which they say should be questioned by patients and their doctors. 

The list includes such common practices as routine electrocardiograms for patients at low risk for heart disease, and antibiotics for mild sinus infections.  It is meant as a set of guidelines.

Dr. Donald Berwick, the former head of Medicare and a longtime quality researcher, called the campaign "a game changer." Part of the reason is that patients generally trust doctors more than insurers, employers or others who attempt to influence what gets covered and what doesn’t.

"This could be a turning point if it's approached with energy," Berwick says. "Here you have scientifically grounded guidance from a number of major specialty societies addressing a very important problem, which is the overuse of ineffective care."

For the most part, the list is non-controversial, avoiding such hot-button issues as prostate-specific antigen testing for prostate cancer, or how often to perform mammography screenings for breast cancer.

But the items on the list include a broad range of interventions that can be revenue-generating for doctors, clinics and hospitals -- and costly for insurers and patients. Some also pose health risks to patients, because they may lead to additional radiation exposure, side effects from medications or unneeded surgeries.

"We need to use this opportunity to raise awareness that sometimes overtreatment or testing can be harmful," says Glen Stream, president of the American Academy of Family Physicians, one of the nine specialty groups participating.

The campaign comes amid a variety of efforts – some called for in the federal health law – to compare the effectiveness of treatments and to change payment incentives to doctors and hospitals to reward quality and penalize inefficiency 

But efforts to slow medical spending growth often become political, spurring fears of rationing or "death panels."

"Anytime you are recommending against a test or treatment, people wonder 'is it for some economic interest?'" notes Stream, who says the evidence-based recommendations are designed to counter those concerns.

Among the items the groups recommend doctors and patients question: X-rays or other scans for uncomplicated headaches or early evaluation of low back pain, exercise electrocardiograms, often called "stress tests" or "treadmill tests" for low-risk patients with no symptoms of heart disease, and chemotherapy for patients with advanced solid-tumor cancers who are unlikely to benefit.

Some of the recommendations go against financial self-interest of the societies or their members because they are likely to result in fewer tests or procedures, Berwick notes. Because of that, some policy experts question whether physician groups will tackle the problem enthusiastically.

A 2011 study in the British Medical Journal, for example, found financial conflicts of interest among many of the doctors charged with drawing up clinical guidelines for diabetes and cholesterol treatments in the U.S. and Canada.

Nonetheless, physicians are becoming more involved in efforts to spread the message that more care is not always better. Other recent efforts to identify medically unnecessary treatments include 37 listed by the American College of Physicians in the Annals of Internal Medicine in January.

And in 2008, the National Priorities Partnership – a collaboration of 28 national health care organizations released its own analysis of overused services, including Caesarean-section deliveries and chemotherapy given to patients in the last two weeks of their lives.

The new campaign, called "Choosing Wisely," is funded by the ABIM Foundation, an arm of the American Board of Internal Medicine. The recommendations will be featured on the website of Consumer Reports magazine, which partnered with the foundation. 

Educational materials will be distributed to physicians. The specialty societies in the campaign include those representing family physicians, cancer doctors, cardiologists, radiologists, gastroenterologists, allergists and kidney specialists. Another eight specialty groups – representing rheumatologists, pathologists, head and neck surgeons and others – are expected to release their own lists in the fall.  

While calling the campaign "magnificent and long overdue," another quality expert noted that most physicians are already aware that most listed procedures are overused.

"This is important, but obviously a first step ... classic low-hanging fruit," says Steve Pearson, president of the Institute for Clinical and Economic Review, which evaluates medical treatments and is affiliated with Harvard Medical School.

He adds that many would find it remarkable that “it’s still required to tell physicians not to do these things.”

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