June 20, 2012

Do I Need That Annual Physical and All Those Tests? Part 2: Questionable Tests

The impetus for most of the recent media reports questioning the value (or at least the frequency) of many tests and procedures comes from the Choosing Wisely campaign initiated by the American Board of Internal Medicine (ABIM) Foundation. Last April, it published a list of 45 overused tests and procedures that physicians and patients should think twice about.

The Choosing Wisely campaign was sparked by a 2010 article in the New England Journal of Medicine by medical ethicist Howard Brody, MD, PhD, who challenged each specialty medical society to produce a list of
overused tests or procedures. Here's what he proposed:
The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.
The ABIM Foundation followed up on this proposal by sponsoring the Choosing Wisely project and encouraging other specialty societies to join in. The list of 45 questionable tests and procedures released in April came from nine societies. The Foundation has also recruited nearly a dozen consumer groups, including Consumer Reports, to help disseminate the reports.

No Outright Bans
The Choosing Wisely list is all about good judgment, not curtailing care, the medical specialists say. The list of 45 questionable tests and procedures runs the gamut from the cautionary "don't diagnose or manage asthma without spirometry" (from the American Academy of Allergy, Asthma & Immunology) to "use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely" (from the nuclear cardiologists' society).

Christine Cassel, MD, president and CEO of the ABIM and its Foundation, said in releasing the list: "It's about cutting waste; it's not about rationing."

The ABIM Foundation says eight other medical societies plan to release their lists this fall.

No health plan insurers have announced any changes in compensation or pre-approval for items on the list, and those sponsoring the list say insurers should not use it that way. But some physicians worry that the list might eventually have that effect.

Ten Medical Tests You May Not Need
According to the medical specialty societies, here are some of the tests you may not need:
  1. A CT scan or MRI after fainting. If your behavior is normal (no seizures or neurological problems), then a brain scan is unlikely to improve your outcome.
  2. An annual cardiac stress test. If you're healthy otherwise, repeating the test every year or so rarely changes the course of your treatment. But additional tests could lead to more invasive tests and unwanted radiation, according to the American College of Cardiology.
  3. A chest x-ray before outpatient surgery. If you have a moderate to good heart you probably don't need a heart scan as part of your assessment before low-risk surgery.
  4. A back scan within the first six weeks of lower back pain. When a physical exam of your back fails to find the source of your pain, a back scan isn't likely to reveal the source of the pain and hence won't improve the outcome.
  5. A repeat colorectal cancer screening. Beginning at age 50, one high-quality colonoscopy every 10 years is all you need if your results are normal.
  6. An annual EKG. For healthy people with no symptoms of heart disease, the electrocardiogram is more likely to mislead than to identify early disease, thereby leading to further needless tests -- like CT scans with their accompanying radiation -- and perhaps unnecessary drugs or surgery.
  7. Annual blood work. Routine blood tests are no longer recommended for people who feel well. Again, false positives are common.
  8. Annual cholesterol test. Adults need these only once every five years after having a test with normal results.
  9. Annual PAP smear. This test for early detection of cervical cancer is needed only once every three years after a normal test result.
  10. Bone scan to detect osteoporosis for women under age 65. These often result in patients taking unneeded drugs that produce side effects.
Missing from this list is probably the most controversial of the 45 recommendations -- that the prostate-specific antigen test no longer be given on a routine basis. My urologist has agreed to give me his views on this recommendation, but we haven't found a mutually convenient time to chat. When we do, I'll recap our conversation here.


Hazel said...

 I suspect our reactions will depend, at least in part, on our own health profiles. I'm glad I had screening for osteoporosis in my 50s - it has been treated and my bones now scan with only a slight weaking in the neck. My lower back/hip scans are good. I'm glad I took the Fosamax, and now also glad to have stopped it. I would not miss a PAP smear for anything in the world, and my annual blood work turned up a vitamin D deficiency as well as high cholesterol, which have been treated. 
   As for the PSA test - I do SO STRONGLY disagree on this one! Too many men I know have turned up with prostate cancer. Those who caught it early are in great shape (or, well, one of them lived a long time after diagnosis) and the one who skipped his physical one year has aggressive cancer. 
   It's such a personal thing, I think ... I just don't have a solution to offer. CT or MRI after fainting? Maybe. But not the standard screenings that help some of us avoid killer diseases.

Patricia said...

Have to agree with Hazel, depends on individual medical health and age...some tests needed others no. I would not skip annual blood work and mamo but that's me.

John said...

Agree.  I'm leery of any "one size fits all" mandates, particularly when it comes to health care.  I strongly believe I have to take an active role in managing my own health care and just go along with the mandates and prescriptions  that may work for most but not necessarily for me.