NPA Names 'Top 5' Cost Drivers in Primary Care

An earlier version of this article incorrectly identified the journal in which the NPA study will be published.

A study in an upcoming issue of the Archives of Internal Medicine has created a field-tested "Top 5" list of potentially unnecessary cost drivers for primary care that -- if limited -- could improve cost and efficiency.

Stephen R. Smith, MD, a family medicine physician in New London, CT, and a lead author of the study published Monday in the online edition of AIM – told HealthLeaders Media that primary care physicians are often motivated to perform unnecessary and costly practices either out of habit, or because of defensive medicine. Patients also pose a challenge. 

"The other thing is we heard from a lot of field testers that looked at this list and gave us an opinion was 'Yes the evidence is there and we agree, But it's going to be difficult to get the patients to go along with this too,'" Smith says. "Sometimes patients come in with misunderstandings. So, it's a matter of also changing patient perceptions."

The list of recommendations – compiled by the National Physicians Alliance project -- suggest limiting antibiotics for some respiratory infections, avoiding imaging for low back pain and osteoporosis screening for certain patients, and not ordering cardiac screening tests in low-risk patients.

The NPA, working on a grant from the American Board of Internal Medicine Foundation, held a Good Stewardship Working Group teleconference to identify cost-saving, efficiency improving practices in family medicine, internal medicine, and pediatrics. The list of suggestions was culled after they were weighed against evidence in scientific literature.

Members of the specialty working groups recruited other physicians to test the suggestions in the field; each of the 83 testers rated the activities by way of an online survey. A mass e-mail to all NPA members recruited 172 other physicians for a second round of field testing, which involved completing the same survey that the initial testers completed. "Each activity was to be well supported by evidence, have beneficial effects on patient health by improving treatment and/or reducing risks, and, where possible, reduce costs of care," the article said.

According to the study, the field testers agreed with the following practices:

• Family medicine—limit early imaging for low back pain, avoid routinely prescribing antibiotics for sinus infections, avoid ordering electrocardiograms or other cardiac screening in low-risk patients with no symptoms, reserve Pap tests for patients age 21 years or older who have not had hysterectomy for benign disease, and reserve dual-energy X-ray absorptiometry osteoporosis scans for women ages 65 years and older and men 70 years and older or who have risk factors
• Internal medicine—limit early imaging for low back pain, do not order blood panels or urinalysis for screening in healthy adults with no symptoms, avoid ordering ECGs or other cardiac screening in low-risk patients with no symptoms, limit initial statin prescriptions to generic medications, and reserve DEXA osteoporosis scans for women ages 65 years and older and men 70 years and older or who have risk factors
• Pediatrics—avoid prescribing antibiotics for sore throats unless tests for streptococcus are positive, limit diagnostic imaging for minor head injuries without loss of consciousness or other risk factors, do not refer middle-ear infections (otitis media with effusion) to specialists too early, tell parents to avoid giving children over-the-counter cough and cold medicines, and ensure that inhaled corticosteroids are used properly by patients with asthma

The NPA plans to distribute the Top 5 lists for each specialty to its members in those fields, create training videos to help doctors communicate the value of these behaviors, and create videos that explain to patients why the steps on the Top 5 lists should be taken, and reach out to consumer groups and patient-safety groups for their endorsements.

Although the study focuses on primary care physicians, Smith says he hopes that specialists will take up the challenge and identify cost-savings and inefficiencies in their own realms. "The specialists have just as much responsibility. But this is where we wanted to start. It seems like a good beginning and hopefully it will lead to other specialists doing the same," he says.