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Choosing Wisely… thinking about medical tests, procedures, and treatments differently

Pam Koenig, FNP

EHC Post Date: Fri, Mar 14th, 2014

Margaret is 88 years old, has severe dementia and lung cancer.  When Margaret's breathing became more difficult with a pronounced 'wet' cough, her daughter requested a CT scan of Margaret's lungs "to find out just what we're dealing with".  Margaret's medical provider explained to her family that a CT scan would be of no benefit, would not affect treatment or outcomes and therefore was not recommended.  Margaret's daughter replied "well, Medicare will pay for it and we want it done".

For the past 2 months, Bill, a 46 year old businessman, has had frequent headaches. He has used several over the counter headache medications and has yet to find satisfactory relief. To avoid the inconvenience and cost of a medical appointment, Bill consulted the internet and became convinced he may have brain cancer, an aneurysm or blood clot.  A self-admitted cyber-somniac, Bill has misdiagnosed himself with a horrible, life-threatening illness, goes to his primary care provider and demands blood tests and an MRI to confirm his diagnosis and begin aggressive treatment.

Stephanie, a 34 year old stay at home mom comes to her medical appointment complaining of severe back pain for the past week which interferes with her ability to care for her 3 young children.  Stephanie has tried heat, ice, ibuprofen and acetaminophen which have all proven ineffective in controlling her pain.  Worried, she asks her medical provider for an xray, CT scan, MRI "or something" to determine the cause of her pain and wants stronger pain medication.

Sound familiar? These are very common scenarios in medical offices where many people come in with pre-conceived ideas of the tests, diagnostic studies and/or treatment they should receive.  Many times the requested tests are inappropriate, not indicated, unnecessary, and/or will prove no benefit to the patient while costing unnecessary time and money.

Recognizing the soaring costs of health care and increasingly finite resources, the American Board of Internal Medicine (ABIM Foundation), in partnership with Consumer Reports, launched the Choosing Wisely campaign, in which medical specialty societies develop lists of five tests or procedures in their specialties that are overused, and whose necessity should be questioned and discussed by medical providers and patients.  Christine Cassel M.D., past President and CEO of the ABIM Foundation reports that $800 billion or 1/3 of what is spent on health care every year is wasted, not necessary and sometimes harms patients.

Choosing Wisely encourages discussion and education about the overuse of tests, procedures and treatments.  Patients are challenged to think about medical care differently, accept care supported by scientific evidence, and not duplicative of tests or procedures already received.  Medical providers are encouraged to engage patients in developing a treatment plan using evidence-based guidelines, smart, effective choices, and appropriate, necessary care for an individual's situation that will lead to significant health benefits, and reduce risk, harm, and costs.

Michael LeFevre, MD, MSPH, Family Medicine Professor and Vice Chair, Department of Family and Community Medicine at the University of Missouri states that although it is sometimes easier to do more rather than less "we need to correct the common misperception held by both doctors and patients that "more is better".  Patients need to be informed that not every test or medication available is needed, and that many carry some risks. Possible risks include diagnostic radiation exposure, unnecessary follow-up testing based on false positive results which can lead to possible harm, adverse medication effects, and treatment complications.

Common practices which Choosing Wisely discourages include unnecessary xrays or other radiographic imaging for low back pain of 6 weeks or less duration; use of antibiotics for acute sinus infection or cold symptoms; annual cardiograms for patients without symptoms or high risk factors for cardiovascular disease; pap smears in women under 21, in women after hysterectomy for non-cancer disease, and in women older than 65 who have had adequate prior screening and are not at high risk for cervical cancer; and routine bone density studies to screen for osteoporosis in postmenopausal women younger than 65 or men younger than 70 without risk factors.

Choosing Wisely asserts that medical providers have an obligation to their patients, their profession, and society to oversee use of medical resources.  This means commitment to evidence-based prescribing and test ordering, and reducing overuse of healthcare resources in the US toward making medical care more efficient and affordable for all.

Patients have the responsibility to engage in dialogue with their health care providers, ask questions and be informed, prudent consumers of health care resources.  Together, medical providers and patients can make a significant difference in curtailing unnecessary overused tests, treatments and soaring health care costs.

For more information log onto: http://www.choosingwisely.org/about-us/ and http://www.choosingwisely.org/grantees/maine-quality-counts/

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