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Leading organizations create lists of commonly used tests, procedures
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Nine US medical societies representing 374,000 physicians released lists of “Five Things Physicians and Patients Should Question,” in recognition of the importance of physician and patient conversations to eliminate unnecessary tests and procedures and, ultimately, improve care.
Using current evidence about management and treatment options, the lists, including one developed by the American College of Cardiology, include recommendations that can make the biggest impact on patient care, safety and quality. All lists were released as part of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation.
“We believe that providing quality care guided by the latest research and guidelines is the best way to manage health care resources,” James W. Fasules, MD, FACC, senior vice president of advocacy at the ACC, stated in a press release. “Informed conversations between physicians and patients are a critical element of quality care.”
Goal to improve CV care
The ACC identified the following five recommendations to help support physicians in working with their patients to make wise choices about their care:
- Cardiac imaging tests — particularly stress cardiac imaging or advanced noninvasive imaging — should not be performed if there are no symptoms of CVD or high-risk factors such as diabetes or peripheral arterial disease.
- Cardiac imaging tests should not be given as part of routine, annual follow-up in asymptomatic patients. An exception to this recommendation would be for patients more than 5 years after CABG.
- Cardiac imaging tests should not be given prior to performing low-risk surgery that is not related to CVD.
- Echocardiography should not be used as routine follow-up care in adults with mild, asymptomatic valve disease who have had no change in signs or symptoms.
- Patients experiencing a MI and undergoing percutaneous coronary intervention should not have stents implanted in nonculprit lesions.
Asymptomatic, low-risk patients account for up to 45% of unnecessary stenting, according to information provided by ChoosingWisely.org. In addition, performing stress tests or advanced noninvasive imaging in asymptomatic patients on a serial or scheduled pattern rarely results in any meaningful changes in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure, the experts said.
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The ACC’s list is comprehensive, Robert O. Bonow, MD, Goldberg Distinguished Professor of Cardiology and director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine, told Cardiology Today. However, the ACC list mentions that a repeat echocardiogram is not necessary in patients with mild valve disease. Bonow said there are some cases in which a repeat echocardiogram may be warranted in a patient with seemingly mild valvular heart disease.
“To recommend that a physician should never do an echocardiogram again could be misleading, especially if the physician caring for the patient is not a cardiologist, but an internist or another health care professional who may not be able to pick up when a murmur is changing, for example,” Bonow said.
The American Society of Nuclear Cardiology released a similar list, calling for less use of stress cardiac imaging or coronary angiography in asymptomatic patients, unless high-risk markers are present, or when performed as a preoperative assessment in patients scheduled to undergo low- or intermediate-risk noncardiac surgery. The group also does not recommend radionuclide imaging as part of routine follow-up in asymptomatic patients, as it rarely results in meaningful changes in patient management. Methods to reduce radiation exposure in cardiac imaging are recommended whenever possible, including not performing such tests when limited benefits are likely, while maintaining high-quality test results.
“These lists open the door for communication between physicians and patients, and may drive both to ask why certain tests or procedures are or aren’t being done,” Bonow said during the interview. “Personally, my patients have asked me the reasons why I do not do a stress test every year.”
Overuse in the United States
Most experts agree that the current health care delivery in the United States contains too much waste — some say that as much as 30% of care delivered in this country is duplicative or unnecessary and may not improve patient health, according to ChoosingWisely.org.
“These lists serve as a reminder that there have been concerns about the frequency and use of certain tests. As physicians, we need to make informed decisions and ensure that we are not performing tests or procedures as a routine, but rather are doing them when there is a real clinical indication,” Bonow said.
However, he noted that there may be as much underuse of specific tests and procedures as there is overuse. He said it is unclear if there will be cost savings simply by not performing tests or performing them less frequently.
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The release of these lists is just the beginning of a bigger initiative, said W. Douglas Weaver, MD, a member of the Practice Management and Quality Care section of the Cardiology Today Editorial Board.
“In this era of belt-tightening, physicians need to take and teach fiscal responsibility to reduce health care costs. From a physician standpoint, if you are unsure of the value of doing an imaging test, for example, or if it is contrary to the guidelines, unless you have a really good reason it probably should not be done.
“The goal is to heighten awareness for physicians that, with our pens, we influence a great deal of the cost of health care,” Weaver said in an interview.
Future efforts
New societies will join the campaign and release lists in the fall.
To read lists provided by other medical societies and to learn more about this campaign, visit ChoosingWisely.org. – by Katie Kalvaitis
Disclosure: Drs. Bonow and Weaver report no relevant financial disclosures.