21 Mayıs 2013 Salı
Putting Tests to the Test: Many Medical Procedures Prove Unnecessary and Risky - Tara Haelle (Scientifc American)
The routine use of 130 different medical screenings, tests and treatments are often unnecessary and should be scaled back, according to 25 medical specialty organizations. The medical societies jointly released lists of tests and therapies patients should question in their campaign, Choosing Wisely. The initiative of the American Board of Internal Medicine Foundation is aimed at reducing unnecessary interventions that waste money and can actually do more harm than good.
A 2012 report by the Institute of Medicine estimated that $750 billion—about 30 percent of all health spending in 2009—was wasted on unnecessary services and other issues, such as excessive administrative costs and fraud. Many of those unnecessary services appear on the new lists released in February from Choosing Wisely. An additional 90 medical services were added to the 40 items initially listed by the campaign in April 2012.
Some of the items on the lists are familiar. Patients should avoid scheduling nonmedically indicated labor inductions or cesarean sections before 39 weeks, for example. Others are designed to reduce the use of expensive and often unnecessary imaging tests, such as early use of magnetic resonance imaging (MRI) or computed tomography scan (CT) scans for complaints that will likely go away on their own. For example, the American Academy of Family Physicians (AAFP) recommends that unless red flags are present, doctors should wait six weeks to order imaging for low back pain. The scans do not affect treatment or improve outcomes any faster for patients—but it can lead to radiation exposure and unnecessary surgery.
Other list items may surprise patients. The American College of Obstetricians and Gynecologists recommends that women 30 to 65 years old who are not at high risk for cervical cancer skip the annual pap smears; the research shows that conducting screenings every three years works just as well.
The idea that excess tests are unhelpful is not new. Charles Tullius, an anesthesiologist at South Pittsburgh Anesthesia Associates, says members of his profession stopped doing many routine preoperative tests decade ago because they led to too many false positives that did nothing but delay surgery. “A lot of these screening tests are fishing expeditions,” he says. “They’re very low-yield.” It’s worse than that: it is becoming clear that many once-routine tests may actually cause harm. But the idea of a test causing harm can be difficult for people to wrap their heads around.
More care isn’t better care
“We are, I hope, at a turning point in American health care where we’re realizing you want to have the right health care, not just more health care,” says Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chair of the U.S. Preventive Services Task Force. Moyer points out that mammography use is responsible for about 20 percent of the cases of overdiagnosis of breast cancer. In fact, the Task Force came under fire a few years ago for recommending fewer women receive routine mammograms—even though the recommendation was based on evidence about providing the best care to women. “As our diagnostic tests get better and better, we can find all kinds of things that are of no consequence,” Moyer says. “If you find something that wasn’t going to hurt you during your lifetime and you treat it, it can only hurt you.”
Sometimes a screening leads to a false positive, after which additional tests can expose patients to unnecessary radiation or even biopsies, which carry their own risks. Other times an imaging test may pick up an abnormality or even a cancer that simply is not life-threatening. Moyer points out that women have gotten mastectomies to treat small, nonaggressive cancers that were never going to affect them. “That’s a huge harm,” she says. Yet it can be difficult to convince people that it’s okay to simply live with a cancer.
“The assumption has been throughout history that the more you know about human normal function and disease, the better equipped you are to treat disease and restore health,” says James Froehlich, the director of vascular medicine at the University of Michigan Medical School. “There are two problems with that. One is the assumption that the goal of medicine is to make people normal again. The other fallacy is that attempts to do so will lead to better outcomes.”
Researchers are finding that trying to make patients “normal” again or even finding out if a patient has something “abnormal” can lead to harm without changing the course of a disease or a patient’s outcome. Aside from excess radiation or treatment side effects, the often debilitating anxiety that screenings can cause are also harmful, says Rich Sagall, a family medicine physician in Gloucester, Mass. “One question every patient should ask before submitting to any test is, ‘How will the results of this test influence the treatment plan?’” Sagall says. “Oftentimes it turns out it won’t.”
That question also gets to the heart of another goal of Choosing Wisely: improving patient–doctor shared decision-making.
Improving communication between patients and providers
Froehlich points out that the health care industry is much less efficient at providing consumers with information than almost any other industry. “It’s been frequently commented that you can make a more informed decision about a car than about a surgeon,” Froehlich says. “The point is that we all have a better idea of whether the brakes need to be changed than if we need a CT scan. This campaign is meant to empower a dialogue so there’s a better discussion about tests and procedures.”
That dialogue is most successful, though, when consumers understand before they get sick that screening and treatment can cause harm. “It’s hard to process more complicated decision-making if I’m already sick,” says Glen Stream, a member of the AAFP. “It’s better if I’ve already given some thought to the idea that perhaps the best treatment is no treatment.”
Understanding risk-benefit analysis of procedures can also help reduce the influence of fear on decision-making. “Post-diagnosis is a hard time to begin that conversation, because the patient is scared,” says Daniel Barocas, an assistant professor of urology at Vanderbilt University Medical Center. “If you tell someone they have what they perceive as a lethal disease, they’re going to seek treatment. This effort encourages discussions where doctors and patients can let data and evidence run the show a little instead of emotionality and fear.”
Barocas says he therefore counsels his patients before any tests for prostate cancer that they may “find something called cancer that doesn’t need treatment” because low-risk, slow-growing prostate cancer is often unlikely to harm a man before he dies of other causes. “I make them promise me they’ll listen to me longer than the word ‘cancer’ before deciding what they want to do,” he says. But he adds that this campaign doesn’t mean screenings have no value. “None of these is a ‘never’ event,” Barocas says. “It’s just not something you have to do routinely.”
Stream, the spokesperson for the AAFP’s involvement in the Choosing Wisely campaign, says making this information available to consumers also can help them navigate the “wilderness” of the health care system with family physicians helping guide them. “We want to see this progress to the point where it’s not an initiative but a movement,” Stream says. The dialogue about when tests and treatment should and shouldn’t be done, he says, “should be part of the new normal.”