Patrick J. Skerrett

Doctor groups list top overused, misused tests, treatments, and procedures

In a proactive effort to help stem healthcare spending, nine medical specialty organizations have published their top 5 lists of tests, treatments, or services that are unnecessary or at least should include a thorough conversation between patients and their doctors regarding the benefits and risks of before undertaking the procedure.

The lists are part of a campaign called Choosing Wisely, organized by the American Board of Internal Medicine Foundation. The medical societies, for example, advise against immediately prescribing antibiotics for sinusitis, ordering an MRI during the initial evaluation of back pain, and doing an exercise stress test for people who don’t have any signs or symptoms of heart disease. (See the top two “dont’s” from each specialty below, or visit choosingwisely.org to see all 45.) Eight more medical specialty organizations are planning to join the campaign.

The purpose of making these lists, says the foundation, is to help doctors and their patients talk about tests and procedures in order to choose the ones that:

  • are supported by evidence
  • don’t duplicate other tests or procedures
  • are free from harm
  • are really needed

Spending healthcare dollars wisely

In a recent article in the Journal of the American Medical Association, former Medicare administrator Dr. Donald Berwick and a colleague argue that as much as $900 billion dollars of health care spending is wasted each year. A big chunk of this comes from doctors ordering tests that yield little useful information or performing procedures that don’t make their patients better. This happens for several reasons. Some doctors just don’t know which procedures or tests are useful and which ones aren’t. Some order useless tests because their patients expect or ask for them. Others do it to protect themselves from possible lawsuits.

Take the exercise stress test as an example. It involves walking on a treadmill while monitors record the heart rate, heart rhythm, and blood pressure. It’s a useful test for people who have symptoms that might indicate heart disease, like chest pain when they are active or under stress. But as with many tests, it isn’t useful just to “check under the hood” in people who feel fine.

About 15% of the time, an exercise stress test suggests that there may be a heart problem, when in fact there isn’t. These “false-positives” can lead to needless worry and further testing, often including an invasive angiogram. To perform that test, a doctor must insert a thin wire and plastic tube called a catheter into a blood vessel in the groin and maneuver it into the heart. Angiogram-related complications aren’t rare.

And if the test shows a narrowing in an artery, many doctors and their patients are prone to fixing it with angioplasty and placement of a stent—which also can have complications and long-lasting repercussions—even though doing this won’t make the person feel better, protect him or her from having a heart attack, or live longer.

More isn’t better

Avoiding tests and procedures that aren’t effective or useful saves time and money, and protects the recipients from harm. For the Choosing Wisely campaign to be a success, all of us—doctors and their patients alike—must stop believing that if some medical care is good, more is better.


Top two “don’ts” from 9 medical specialty organizations

American Academy of Allergy, Asthma & Immunology

  • Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, when evaluating a possible allergy.
  • For uncomplicated acute sinusitis, don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics.

American Academy of Family Physicians

  • Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
  • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

American College of Cardiology

  • When initially evaluating patients who are not having cardiac symptoms, don’t perform stress cardiac imaging or advanced non-invasive imaging unless there are markers the patient is at high risk.
  • Don’t perform stress cardiac imaging or advanced non-invasive imaging as part of routine follow-ups in patients without symptoms of cardiovascular disease.

American College of Physicians

  • Don’t perform exercise electrocardiogram testing (exercise stress test) in patients who do not have any symptoms of heart disease and who are at low risk for coronary heart disease.
  • Don’t obtain imaging studies in patients with non-specific low back pain.

American College of Radiology

  • Don’t do imaging for uncomplicated headache.
  • Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

American Gastroenterological Association

  • When prescribing long-term acid suppression therapy for gastroesophageal reflux disease (GERD), choose the lowest dose of a proton pump inhibitor or histamine2 receptor antagonist to achieve therapeutic goals.
  • Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

American Society of Clinical Oncology

  • Don’t use cancer-directed therapy for patients with a solid tumor who have the following characteristics: low performance status, no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.
  • Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

American Society of Nephrology

  • For patients on dialysis who have limited life expectancies, don’t perform routine cancer screening unless the patient has signs or symptoms of cancer.
  • Don’t administer drugs that stimulate red blood cell production in patients with chronic kidney disease who do not have symptoms of anemia if their hemoglobin levels are greater than or equal to 10 g/dL.

American Society of Nuclear Cardiology

  • Don’t perform stress cardiac imaging or coronary angiography in patients without signs or symptoms or cardiac disease unless they have other markers indicating they are at high risk for cardiac disease.
  • Don’t perform cardiac imaging for patients who are at low risk.

 

Related Information: Harvard Health Letter

Comments:

  1. Joey Peter

    Dear P.J. Skerrett,

    Thank you very much for sharing this info . Our powerful media never expose such things with clarity .

    Lay men don’t have the knowledge to decide whether these tests are necessary or not .

    Josey Peter

  2. Jennifer McLeod

    A very helpful post and people should be aware of this. So much money wasted for unnecessary medical tests.

    Jennifer McLeod
    Self Harm Training Specialist

  3. Ben

    $900 billion dollars of health care spending is wasted each year is a very serious matter. Better to do something about it and look for a best solution. This is a lot of money and with this amount we can help many people if we do the right thing.

  4. aa197j

    Really appreciate you sharing this post. Really thank you! Want more.
    Awesome blog.Much thanks again. Want more.

  5. Robert Root

    I just spent an entire year visiting specialists, as the doctor assures me it’s all deductive reasoning, thank god I was referred to the right specialist BY a specialist or I would have never gotten a proper diagnosis. one can never be too happy about getting a diagnosis after 16 years of suffering, but I must say after the hard work I was quite pleased and have considered framing the damn thing. Thankfully I was able to self treat my sensory neuropathy and I live pain free today. Thank you for the excellent information, Robert Root.

  6. henry

    There is great emotional cost in performing unnecessary medical tests.

  7. jaspreet

    Agreed with the others. There is great emotional cost in performing unnecessary medical tests.

    • Duy

      Isn’t it obvious? It’s a patentiol to defer losses. If you pay for insurance and get very sick/hurt the insurance company will cover a percentage of the bills.Depending on the plan*, but usually the ratio that company pays versus what the insured is payed is about 80/20.So is it better to pay $300 a month in insurance premiums to deflect a big injury by 80/20 if one occurs or is it better to not have insurance and pay 100% if one occurs? You decide your risk tolerance.

  8. shakshi

    Agreed with the others

  9. Linda Zuber

    At a routine dental cleaning yesterday, I again refused to have x-rays as I wasn’t experiencing any problems. The hygenist got hostile towards me because I was refusing them. I tried to explain the multiple cysts on either side of my thyroid gland and one large one that presses on my esophagus, have made me afraid to have anymore radiation if I’m not having a problem. She has never pushed my husband or brother on this subject; she mentions it and they say “no” and that’s that. Today, I see there is a paper published by Harvard and Yale on the correlation between too many dental x-rays and brain tumors. My father died from a glioblastoma which makes me doubly afraid of more radiation, if it’s not necessary. I don’t want to fight with the hygeniest; I feel that should be a discussion between the dentist and me.

    • Jessa

      I agree with you, it’s hard to find medical staff who are educated enough to explain further if it’s really necessary for us. Next time ask her or him to write in black and White and tell her that you’ll reply letter. It’s our life is at stake so we just want what’s best for us. Anyway, stay cool and take care.

    • Moktar

      Because uninsured htelah costs are the #1 cause of bankruptcy in the US. If you ever want to own ANYTHING, like a house, or buy a car on credit, you’d best keep htelah insurance in place. A bad car accident could lay you up for 6 months and give you $250,000 in medical bills, in a minute.

  10. ideal protein diet

    I agree with avoiding tests and procedures that aren’t effective or useful saves time and money. for those rich people who don’t care money, waste their money is okay, but for the poor, test and procedures that is not useful is really wastes the time, therefore, we have to be more selective to

  11. Alun

    Agreed with the others. There is great emotional cost in performing unnecessary medical tests.

    Alun

  12. Mike McDermott

    This is yet more smoke. I had a doctor and hospital deliberately harm my kidney. Although many doctors and organizations, including Harvard’s, have known about me and my plight, I have been completely ignored for over 10 years. Until organizations and doctors stand up to specifically condemn corrupt doctors and hospitals and their practices, corruption will continue to spread with occasional worthless appeasing articles such as this.

  13. abdallah

    i hope to stud master of hematology
    please can you help me
    .i wait replay from you
    thanks

    • Valentin

      i think the best way to know would be to ask students about the iiaretctnon between different ethnic groups (don’t phrase it like “are people racist here?” lol that might offend them) and see what they say. as far as i know, harvard is quite diverse, and i haven’t heard anything to make me think people there would be racist.good luck getting in, its very competitive.References :

  14. Armando Ribeiro das Neves Neto

    Great discussion! It is important to remember that beyond the financial costs and increased iatrogenic risk, there is an emotional cost in carrying out unnecessary tests. The medicine of the future must learn to combine “high tech – high touch.” Armando Ribeiro das Neves Neto. Sao Paulo / SP, Brazil.

  15. Thế Hùng

    I like share, thank very much
    I from Vietname
    http://moitruonghungphat.vn
    Thanks!