Critics charge that many of the interventions identified by medical specialty societies as being unnecessary are rarely used "safe bets," rather than services that have a major effect on revenue.
Choosing Wisely, the initiative in which medical societies identify medical tests and procedures that are not supported by evidence and that doctors and patients should avoid, will soon be four years old.
Happy Birthday Choosing Wisely. This courageous effort, which has racked up 300 recommendations, is changing conversations among hospitals, doctors, and patients.
But four years is old enough, apparently, for some to start chiding it for being too meek, and for not using its growing clout to bear down harder to prevent the use of unnecessary procedures.
|
The "don'ts" and "avoids" are now the target of criticism from those who say many of the 70 medical societies' lists overlook big ticket items that generate big revenue. Value-focused clinicians say many specialty societies instead pick rarely used treatments among their recommendations, perhaps to avoid stepping on a lucrative service line's third rail.
Little Threat to Specialists' Revenue in Choosing Wisely Recommendations
It's a little like saying they're swearing off jelly beans when they never ate jelly beans in the first place. Better they should push away something else of low nutritional value that they crave, like ice cream.
Last year in the New England Journal of Medicine, Nancy Morden, MD, of the Dartmouth Institute for Health Policy and Clinical Practice, blasted some specialty groups for listing no questionable services, such as surgeries, that have a major effect on revenue.
And this week, specific harsh criticism came from Rita Redberg, MD, editor of JAMA Internal Medicine, who says many of the recommendation among the 300 listed so far are "safe bets," in that specialists who named those procedures named ones that were rarely used anyway.
Routine stress testing before low-risk outpatient surgery, almost never ordered for patients today and publicly reported on Hospital Compare for outpatient departments, is a case in point. It is, nevertheless, itemized on seven specialty societies' lists of overused procedures, according to an accompanying commentary in JAMA Internal Medicine.
"It's time for professional societies to be bold and wise," Redberg wrote an in the same edition of the JAMA IM. Such stress testing was uncommon "even before the launch of the Choosing Wisely campaign," she says, admonishing societies to be "bolder in identifying common interventions that add little value to our medical care."
In an interview this week, Redberg went even further.
She pointed to the American Academy of Orthopedic Surgeons, whose Choosing Wisely recommendations "don't address the overtreatment of back pain, though we now know that back pain is better left alone because after six weeks, it's probably going to get better without doing much. And we know 90% or more people will feel great with rest, non-steroidals, and some physical therapy."
Likewise, she says, "I don't see anything in radiology specialists' recommendations" against kyphoplasty," another procedure with dubious benefit for many patients persuaded to undergo it.
Daniel Wolfson, executive vice president and COO of the American Board of Internal Medicine Foundation, which runs Choosing Wisely, vehemently disagrees with Redberg and Morden, saying that the groups' recommendations are bold and getting bolder even as the campaign to educate doctors and patients gets implemented in decision support tools at dozens of organizations.
But Redberg says other organizations' lists don't go far enough with their recommendations. One, on the list of the Society of Nuclear and Molecular Imaging, says "Don’t perform routine annual stress testing after coronary artery revascularization."
A cardiologist at UCSF Medical Center, Redberg, says it should say, "Don't do annual stress tests in people who are asymptomatic, period. This whole idea of pushing executive physicals, where people get stress tests even though have no symptoms, well there's absolutely no evidence there's any benefit and it often leads to a lot of extra testing and procedures."
And while they're at it, screening tests for asymptomatic people, including cardiac screening, nuclear testing, and coronary calcium scans, "all that should be on the lists." Some of these tests don't give patients a good idea of their heart health, and of course, there's added radiation which increases cancer risk, she says.
Then there are breast cancer screenings. Limits on mammography screening by MRI also should be a topic for recommendation, says Redberg. "Breast MRI is definitely not first line for breast cancer screening, and I don't think it's established for the indication that it's supposed to be used for, women with dense breasts." It's not on anybody's list.
Some societies, however, have shown courage, Redberg acknowledges. Specifically, she lauds the American Geriatrics Society for recommending manual feeding, which is more costly, instead of against percutaneous feeding tubes in patients with advanced dementia. And she praises the American Society for Radiation Oncology for its recommendation against initiating management of low-risk prostate cancer "without discussing active surveillance."
That's not only bold, Redberg says, "it's badly needed right now because there's no evidence that most all treatments for prostate cancer have any benefit, but there are a lot of proton beam scanners around. When you spend this kind of money [on equipment], without evidence of who will benefit, you get aggressive marketing that's not in the patient's best interest."
Wolfson says that beyond the recommendations themselves, Choosing Wisely has fostered enormous conversation and thought, and it's helped hospitals embed decision support tools into their systems to prevent procedures whose benefits don't outweigh risks.
"Cedars Sinai Medical Center in Los Angeles has implemented 180 recommendations, and [is] building up to all 300," Wolfson says. Now, hundreds of times a day, "an alert comes on warning clinicians about something—say, you're ordering a CT scan for lower back pain—not recommended by Choosing Wisely."
"This is like wildfire across the country," Wolfson says. A $4.2 million Robert Wood Johnson Foundation grant will expand the campaign for 21 organizations that want to strengthen Choosing Wisely awareness in their healthcare settings.
Non-physician groups such as nurses are adding their recommendations, and while a year ago, there were a few major society holdouts, now there are none, Wolfson says.
A year from now, he adds, "we're going to get better at this. The lists were intended to have a concrete conversation about overuse, and the potential harms of doing more."
Someone said that an organization's job is to champion and defend its initiatives, and the critic's job is to point out what could be much better. That's the right way to think about this.
It's all good.