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Rethinking “Choosing Wisely”

July 19, 2012

The ABIM Foundation is advocating a new campaign called “Choosing Wisely” to help physicians “be better stewards of finite health care resources.” The recommendations in the campaign have been published in Consumer Reports and has been distributed to AARP members. At first glance, the campaign seems to make sense. Limit “unnecessary” testing and decrease costs. However, I predict that the “Choosing Wisely” campaign will also have many less desirable effects. I picked out a few random examples of current “Choosing Wisely” recommendations to illustrate some of the problems that I perceive will occur.

The American College of Physicians recommended that we “Don’t obtain imaging studies in patients with non-specific low back pain.” Notice how the ACP didn’t describe how to classify back pain as “non-specific” prior to testing? Third party payors will be citing this recommendation routinely. Any back pain imaging that shows no pathology is likely to be retrospectively labeled as “unnecessary” because the back pain was “non-specific.” What if a patient has urinary retention with his acute back pain? Would anyone argue that an urgent MRI wasn’t indicated? However, the MRI shows nothing but an enlarged prostate and the urinary retention was probably just caused by the opiates the patient was taking for the pain. Retrospective diagnosis: Unnecessary test. Doctor should have known better. Patient gets stuck with bill.

The American Society for Clinical Oncology recommended that we “Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
Isn’t the idea of cancer survival to catch things early? By the time we wait for an asymptomatic metastasis to become symptomatic so that testing is “appropriate,” the cancer will most likely be too late to treat. Using this recommendation, third party payors will refuse to pay for follow up screens because they are “unnecessary.” Patients won’t get the testing, and more patients will die from cancer recurrence. Are most surveillance tests normal? Of course. But instead of having a group of “stewards” act as barriers to testing, patients should be presented with data regarding the effectiveness of the testing and then make an informed decision as to whether they want to have the testing performed. If ASCO truly believes that surveillance testing is inappropriate, it should check its own web site. The recommendation against surveillance testing isn’t even one of its own clinical practice guidelines for breast cancer. And if you look at ASCO’s recommendations for use of tumor markers in breast cancer, the Society DOES recommend use of some tumor markers which seems to contradict their own “Choosing Wisely” recommendation (“The following categories showed evidence of clinical utility and were recommended for use in practice: CA 15-3, CA 27.29, carcinoembryonic antigen, estrogen receptor, progesterone receptor ….”).

The American College of Radiology recommended that we “Don’t image for suspected [pulmonary embolism] without moderate or high pre-test probability of [pulmonary embolism].” The actual incidence of pulmonary embolism in patients with a low pre-test probability of pulmonary embolism is between 4% and 15%. Adhering to ACR recommendations, doctors would miss up to 1 in 7 cases of pulmonary embolism. About one in three patients with untreated pulmonary embolism die, meaning that up to 5% of patients with low pre-test probability of a pulmonary embolism would die using the ACR recommendations. Even if we obtain a normal D-dimer assay in patients with a low pre-test probability of pulmonary embolism, the incidence of pulmonary embolism in patients is still 0.7% to 2.0%. There is no test that detects pulmonary embolism 100% of the time, but shouldn’t patients be making an informed decision whether or not they wish to have testing performed to help decrease the likelihood of this potentially deadly disease?

To push the “steward” envelope in decreasing the number of imaging tests being ordered, the American College of Radiology has even created its own “Image Wisely” campaign. However, radiologists aren’t the ones who get sued for failing to order imaging tests — they’re only liable for failing to properly interpret tests that other doctors order. By telling other physicians not to order that testing, the radiologists look like great stewards, but have no skin in the game. If the American College of Radiology wanted to have an impact upon the amount of radiologic testing being ordered, it would have created an “Interpret Wisely” or a “Report Wisely” campaign to deter its members from recommending low yield follow up studies on questionable x-ray abnormalities.

While there are many appropriate entries on “Choosing Wisely’s” list (we don’t need antibiotics in acute sinusitis, folks), many of the “Choosing Wisely” recommendations either have little applicability or are just too vague. Even recommendations that make good clinical sense don’t appreciably affect the project’s stated goals. How much of our country’s “finite resources” will be saved by refusing that unnecessary $4 amoxicillin prescription for sinusitis, anyway? Many of the recommendations in this project will give bean counters extra ammunition to use against us in determining our worth as physicians, in determining whether we are appropriately compensated for our services, and in shaping a negative public opinion about how uncaring physicians perform “unnecessary” and “wasteful” testing and treatments.

In addition, many of the tests that “Choosing Wisely” recommends withholding from patients have some element of physician judgment involved in deciding whether the test is indicated. See catch phrases such as “low-risk”, “asymptomatic” and “non-specific” within the current “Choosing Wisely” recommendations. These “judgment calls” limit the applicability of the recommendations, but don’t we see where this is headed? Like the “non-specific” back pain example above, once a test has been interpreted as being “normal,” third parties are going to retrospectively second guess the physician’s judgment in order to avoid paying for the test: “The doctor misclassified the patient as ‘intermediate-risk’ when the patient was really ‘low-risk’ and therefore [insert name of negative test] was not indicated.” Insurance companies will have an incentive to use this discretionary language to refuse pre-authorization for expensive testing or treatments and to deny payment for tests that were performed.

Before any tests or treatments make the “Choosing Wisely” list, there should be proof that the involved activities are truly “unnecessary” and that no harm to patients will come from excluding those tests. If, instead, the tests are deemed “low yield” or “discretionary” an evidence-based assessment of the risks and benefits of the testing or treatment, including a summary with projected cost savings and projected morbidity and mortality, should be published along with the recommendation and the public should be allowed to comment on the summaries and recommendations. Using this information, patients could then decide whether or not they are willing to forego the testing and/or treatment based on their own assessment of the risks and benefits of the testing or treatment. Doctors need to focus upon informed consent, not upon paternalism.

“Choosing Wisely” also needs to emphasize that many low-yield tests are performed due to a fear of lawsuits and that those discretionary tests might not be necessary if physicians were not held liable for failing to diagnose highly unlikely diseases or for failing to prolong the lives of terminally ill patients by a few months.

The “Choosing Wisely” campaign has good intentions, but isn’t a good idea. There isn’t a “Suing Wisely” campaign for attorneys and there isn’t a “Legislating Wisely” campaign for Congress. The amount of discretionary medical testing performed in this country is undoubtedly excessive, but in order to diminish the amount of discretionary testing, we shouldn’t erect barriers to performing those tests. Instead, we should help our patients understand that medicine will never be “perfect” and that sometimes “doing everything” or “getting every test” isn’t in a patient’s best interests. Until we impart this wisdom upon our patients, it is unlikely that any recommendations from a “Choosing Wisely” campaign will be routinely followed.

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Dr. Kevin Pho has also graciously cross-posted this article on KevinMD.com

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3 Comments leave one →
  1. July 22, 2012 10:01 am

    There is, of course, a potential to benefit both individual patients AND the public at large by eliminating unnecessary tests and procedures. No one will argue that avoiding unneeded exposure to radiation or the risks of an invasive biopsy is bad. If we can save some dollars to provide better care to more people, that too is a beneficial thing.

    There is however, a dark side to all of this; a dark side to…dare I say it?…evidence based medicine.

    We once thought of medicine as an “art”; to me it has always been the art of applying scientific knowledge to an individual human being’s situation. All of these recommendations, guidelines, standards, and protocols if misused, can take the art out of medicine, give ammunition to those who’s true motivation is solely financial, and have the potential to do great harm. If government and private insurers decide not to pay for some of these tests; patients won’t be able to afford them and access to care will be eliminated. With the discretion taken away from the individual physician, who is left to advise on the balance of risk and benefit for the individual patient? No one.

    I want to thank Dr. Sullivan for his courage in writing this important and thoughtful post. There are no simple issues when it comes to healthcare.

    Our new blog, called Vitals & Verdicts, will be launching Aug. 5 to explore issues related to health law, healthcare leadership, and medical and health law practice. We will be starting off with an exploration of the issues surrounding evidence based medicine. Please stop by and take a look at http://www.vitalsandverdicts.com. Also feel free to stop by our Facebook page at http://www.facebook.com/vitalsandverdicts; we will be posting items there for comment until the blog launches.

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  1. Cost Effective Care in the Emergency Department - Developing Meaningful Strategies - THE FICKLE FINGER
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