Explained: Choosing Wisely Initiative

CRegal Editor
  • Choosing Wisely, an initiative set forth by the American Board of Internal Medicine, released a series of recommendations designed to reduce costs of medical care throughout the United States.

     

    What's the problem?

    Medical health expenditures are skyrocketing in the United States, where the overutilization of services is one of the driving forces behind this dramatic cost increase.  There is concern - and evidence to support it - that physicians, at times, administer tests or treatments that may not be necessary for the first level of analysis.  One of the common examples given is with regard to "routine" screenings which cost thousands of dollars and may not make a real difference for the patient.   There is even concern that some unnecessary procedures are, in fact, harmful to the patient.  As a means of scaling back unnecessary expenditures and risk, the ABIM has created a working group to decide which procedures are truly necessary and which should be used at the discretion of a doctor. 

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    How did they address this?

    A coalition of nine medical specialty associations sought to name five procedures in each specialty area.  The nine specialty societies were: American Academy of Allergy, asthma and Immunology, American Academy of Family Physicians, American College of Cardiology, American College of Physicians, American College of Radiology, American Gastroenterological Association, American Society of Clinical Oncology, American Society of Nephrology and the American Society of Nuclear Cardiology.  Each group put forth a list of five tests, treatments or services that are deemed unnecessary. 

     

    Some of the recommendations may seem familiar or to be common-sense.  The impact of this study, specifically, is that the nine societies represent a combined 374,000 practicing physicians.  A coordinated effort such as this will leave a large footprint in the medical community, far more than any one group has been able to do in the past. 

     

    What did they recommend?:

    Included in the recommendations were:

    • Routine heart screenings are not necessary for individuals without symptoms or who are not at high-risk for heart disease
    • Short-term lower back pain does not require advanced imaging, such as MRI or CT scan
    • Antibiotics need not be prescribed for acute sinus infections, nor should advanced imaging be performed
    • Pap smears for women under age 21 are unnecessary
    • Asthma should not be diagnosed or treated without spirometry, the accepted test for the condition
    • Advanced imaging (including MRI) is not necessary for an uncomplicated headache
    • CT scans should not be used before an ultrasound in appendicitis cases
    • After a high-quality colonoscopy, a repeat colorectal screening is not necessary for 10 years
    • Physicians should first treat gastroesophageal reflex disease (GERD) with the lowest possible dosage of medications; increased dosages should only occur if the low dosage is ineffective
    • Advanced scans (ie CT scans) for early prostate and breast cancer are unnecessary
    • Chest x-ray before outpatient surgery is inappropriate

    What does this mean?

  • In many cases, these recommendations will stop "routine" procedures that really do not provide any increased safety to the patient.  Advanced diagnostic tests, such as MRI, CT scan, x-ray, etc. are not necessary unless there are complications with the first-line tests.  These tests are extremely costly and are contributing to the explosion of costs for health care.  This drives up premiums and the public is paying for these exams for those who are on public assistance programs, including Medicare and Medicaid.  There is also concern for prescribing medication when prescription drugs are not necessary (or prescribing a higher dosage than necessary).  Of course, all of these recommendations come with caveats - unless other symptoms are present, unless the condition has shown resistance to treatment, unless a patient is at high-risk for complications, etc. 

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    What's the impact?  

    This may change the way doctors approach a problem.  Rather than taking an aggressive approach to diagnosis or routine exam, this board is recommending that, in order to keep costs and patient risk down, an aggressive approach is not always necessary.  In many of the outlined cases, following the recommended guidelines will not change the ways in which a condition is analyzed or ultimately treated.  Patients, often insulated from "real" costs of medical care through health insurance plans, likely will not see dramatic changes in services. 

     

    The fear from the doctor's perspective may be of litigation - if a person is NOT tested with the most advanced tools and it turns out something is wrong, the patient may sue the doctor.  In order to cover tracks, expensive procedures became routine and every condition required medication.  A cultural shift is in order, both for the physicians and the patients, and these recommendations may be the first step towards reigning in out-of-control medical expenditures.

     

    Source:

    Cassell, Christine K., Guest, James A. (4 April 2012).  Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care.  Journal of American Medical Association 476. doi:10.1001.  Retrieved from http://jama.ama-assn.org/content/early/2012/03/30/jama.2012.476.full.

     

    ABIM Foundation. (2012).  Choosing Wisely. Retrieved from http://choosingwisely.org/?page_id=13.

Published On: April 06, 2012