Journal of Medicine - If health care costs are ever to be brought under control, the nation’s doctors will have to play a leading role in eliminating unnecessary treatments. By some estimates, hundreds of billions of dollars are wasted this way every year. So it is highly encouraging that nine major physicians’ groups have identified 45 tests and procedures (five for each specialty) that are commonly used but have no proven benefit for many patients and sometimes cause more harm than good.
Many patients will be surprised at the tests and treatments that these expert groups now question. They include, for example, annual electrocardiograms for low-risk patients and routine chest X-rays for ambulatory patients in advance of surgery.
The doctors were prodded into action by a conscience-provoking article by Dr. Howard Brody, director of an institute that explores ethical issues in health care, published in The New England Journal of Medicine in early 2010. Dr. Brody criticized the performance of medical groups during the health care debates, saying they were too concerned about protecting doctors’ incomes while refusing to contemplate measures (beyond malpractice reform) to reduce health care costs.
He urged each specialty society, using rigorous scientific approaches, to develop “top five” lists of tests and treatments whose elimination for major categories of patients would save the most money quickly “without depriving any patient of meaningful medical benefit.” A foundation established by the American Board of Internal Medicine financed a successful test of the approach in three primary care specialties and then encouraged a broad range of specialty groups to develop their own lists.
The first nine, including cardiology, oncology, radiology and primary care, issued “top five” lists last Wednesday. Among items on those lists are: cardiac stress tests for annual checkups in asymptomatic patients; brain imaging scans after fainting; antibiotics for uncomplicated sinus infections that are almost always caused by viruses, which are not treatable with antibiotics; imaging of the lower spine within the first six weeks after suffering back pain; and bone scans for early prostate and breast cancer patients at low risk of metastasis.
The societies developed the lists after months of analyses and reviews of the medical literature by expert committees. In some cases, the groups showed admirable statesmanship by proposing cuts that would affect their incomes, as when radiologists proposed limits on various tests they perform and gastroenterologists proposed limits on the frequency of colonoscopies.
Eight additional societies will release their lists next fall, expanding the campaign to cut waste more broadly through the health care system. Ultimately, the societies ought to develop top 10, 20 or 50 lists if there is enough evidence to make that possible.
Patients must take responsibility as well. They must discipline themselves not to request care of little or no value. To help patients make informed decisions, Consumer Reports is developing more-accessible versions of the lists and will join other organizations in disseminating them.
Patients with comprehensive health insurance may not care much if needless tests are performed. But if health care costs continue to soar, patients will be shouldering more of the financial burden. And there can be serious health consequences from unnecessary treatment, including excess radiation, adverse drug effects, exposure to germs in medical institutions and even exploratory surgery or biopsies when scans produce a false positive.
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