Medical test guidelines garner LI support

A new national campaign that gives doctors ways to cut spending through clear guidelines on when to order -- and not order -- medical tests and treatments has won support from some Long Island hospital leaders.

The coalition of nine physician societies, representing 375,000 doctors nationally, urges doctors and patients to ask key questions before performing what could be an unnecessary procedure.

"It will change the way medicine is practiced because I think patients will question the tests much more," said Dr. Mark Jarrett, chief quality officer for the North Shore-Long Island Jewish Health System.

Jarrett said that in the past, patients often expected their doctors to order the tests. "But this will help that conversation between doctor and patient."

The list of 45 guidelines, compiled by the American Board of Internal Medicine and announced Wednesday, challenges the use of a brain scan for those who faint without neurological symptoms; the use of antibiotics for sinus infections; and a Pap test for women younger that 21, among other procedures.

For people without cardiac symptoms or a family history, a routine stress test isn't necessary either, according to the recommendations.

Dr. Steven J. Walerstein, medical director for Nassau University Medical Center in East Meadow, said testing on those who don't have symptoms could set up patients "for a cascade of further tests which escalate cost and put patients at risk." They could be harmed more than helped, he said.

Dr. Christine Cassel, president of the internal-medicine board, said the goal is to cut wasteful spending without harming patients. Some may benefit by avoiding known risks associated with medical tests, such as exposure to radiation.

"We all know there is overuse and waste in the system, so let's have the doctors take responsibility for that and look at the things that are overused," Cassel said. "We're doing this because we think we don't need to ration health care if we get rid of waste," she said.

It's unclear how much money would be saved.

The campaign, called Choosing Wisely, is the latest set of guidelines that urge fewer medical tests for healthy people. A government panel of scientists and public-health experts over the last two years has said some women can delay routine mammograms until 50 and that doctors should stop routinely giving men the PSA blood test for prostate cancer.

It also comes at a time when the nation's health care system is preparing for massive changes and the soaring cost of medical care has focused attention on wasteful spending.

Neither the insurance industry nor the federal government was involved in the process. The medical societies don't have any power of enforcement, and fear of malpractice lawsuits may well prompt many doctors to keep ordering as many tests as ever.

The guidelines, both Walerstein and Jarrett said, will help protect doctors who are asked why they didn't order the tests.

The United States spends twice what other major industrialized countries spend on health care per capita, yet ranks 35th in the world with a life expectancy of 78.3 years, according to the American Board of Internal Medicine. The nation's medical bill hit $2.6 trillion in 2010.

It is estimated that 30 percent of the health care spending is wasted or goes to unnecessary care, said Dr. John Santa, director of the health-rating center at Consumer Reports, a partner in the new campaign.

Santa said there are going to be some people who will say the guidelines are set out to ration health care. He also acknowledged that there are some doctors who are likely unhappy about the lists for fear it will cut their income.

He applauded the medical societies for giving doctors a standard of care.

"These professional groups are not only telling doctors when they should do things but also when they shouldn't," Santa said.

With AP

HEALTH RECOMMENDATIONS

Among the 45 recommendations issued by the Choosing Wisely project:

-- Don't order imaging for low-back pain within the first six weeks, unless red flags are present.

-- Don't order annual electrocardiograms (EKGs) or other cardiac screening for low-risk patients without symptoms.

-- Don't routinely prescribe antibiotics for acute mild-to-moderate sinus infections unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

-- Don't use cancer treatment for solid-tumor patients with end-stage cancer.

other recommendations, please code for the web

-- Don't perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

-- Don't order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

-- Don't routinely do diagnostic testing in patients with chronic urticaria.

-- Don't recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.

-- Don't diagnose or manage asthma without spirometry.

-- Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

-- Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

-- Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

-- Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

-- Don't perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

-- Don't perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

-- Don't perform stenting of non-culprit lesions during percutaneous coronary intervention for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction.

-- Don't obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

-- Don't do imaging for uncomplicated headache.

-- Don't image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

-- Don't do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

-- Don't recommend follow-up imaging for clinically inconsequential adnexal cysts.

-- Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

-- For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed 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.

-- Do not repeat colonoscopy for at least five years for patients who have one or two small dysplasia, completely removed via a high-quality colonoscopy.

-- For a patient who is diagnosed with Barrett's esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.

-- For a patient with functional abdominal pain syndrome computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

-- Don't use cancer-directed therapy for solid tumor patients with certain characteristics.

-- Don't perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer.

-- Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

-- 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.

-- Don't use white cell stimulating factors for primary prevention of febrile neutropenia forpatients with less than 20 percent risk for this complication.

-- Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.

-- Don't administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.

-- Avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

-- Don't place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology.

-- Don't initiate chronic dialysis without ensuring a shared decisionmaking process between patients, their families, and their physicians.

-- Don't perform radionuclide imaging as part of routine follow-up in asymptomatic patients.

-- Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.

-- Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

SOURCE: Choosing Wisely Campaign