Will Fewer Tests Improve Healthcare or Profits?

Earlier this month, the American Board of Internal Medicine (ABIM) Foundation, in partnership with Consumer Reports, announced an educational initiative called Choosing Wisely (1). Nine medical organizations were asked to name five things physicians and patients should question. The initiative lists specific, evidence-based recommendations physicians and patients should discuss to make wise decisions on their individual situation. The list of tests and procedures Choosing Wisely advises against include common procedures and treatments such as EKGs done routinely during a physical examination, routine MRI’s for back pain, antibiotics for mild sinusitis, and routine EKG and chest X-rays preoperatively. Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life (2). We at the Southwest Journal of Pulmonary and Critical Care (SWJPCC) applaud the use of evidence-based medicine in determining testing and treatment. Any information that can inform medical decision making is welcome.

With most of the Choosing Wisely recommendations there is solid evidence that the procedures do not improve patient outcomes (1). Nevertheless several previous efforts to limit testing have failed and even provoked backlashes. For example, in November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment (2). An area of further concern is that the Choosing Wisely recommendations will be used not just to make informed decisions, but by payers to limit decisions that a patient and physician can make. This is especially true since the motivation for these recommendations may not be to improve care but to decrease expenses and increase profits by insurers and other payers.

Several of the quality improvement and training organizations affiliated with the ABIM have recommendations and guidelines that are either non- or weakly-evidence based and have not been shown to improve patient outcomes. Surely, these should also be questioned. These include most of the hospital performance measures for acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care, the ventilator-associated pneumonia guidelines, and the central line associated bloodstream infection guidelines (3-5).  Furthermore, in examining the requirements for recertification by the ABIM, the parent organization that sponsored the Choosing Wisely initiative, the evidence basis for the ever increasing frequency of examinations for ever increasing fees and the quality improvement initiative in individual practices is unclear (6).

The recommendations number only 5 from each society (with several overlapping) and come from only 9 of the over 50 medical societies, organizations and boards affiliated with the ABIM. Why recommendations from other medical societies including pulmonary and critical care organizations such as the American Thoracic Society (ATS)* and the American College of Chest Physicians (ACCP) were not included was not stated. In order to help the ABIM, ATS and ACCP, we list some procedures and treatments below that pulmonary and critical care physicians might consider for inclusion in the Choosing Wisely recommendations:

1. Pneumococcal vaccination with the 23 polyvalent vaccine in adults
2. Chest X-ray after bronchoscopy or needle biopsy in the absence of symptoms
3. Routine use of heparin for deep venous thrombosis prophylaxis 
4. Routine chest X-ray in the absence of clinical suspicion of intrathoracic pathology
5. Pulmonary consultation for bronchoscopy for nonobstructive atelectasis
6. Ordering blood troponin levels in the absence of a clinical suspicion of myocardial infarction
7. Admission of a patient to the ICU who has chosen not to be resuscitated (DNR) and without clear goals of what is be accomplished in the ICU
8. Provision of powered mobility devices where there is not a clear medical necessity. 
9. Diagnosis and management of  COPD without spirometry
10. Developing and calling guidelines “evidence-based” when they are opinion or developed from nonrandomized trials.

Overall, the Choosing Wisely recommendations are a welcome start provided they are put to the use intended by the ABIM and contributing organizations. These should be expanded by contributions from other specialty groups and societies, but only if the evidence basis for each recommendation is clearly stated and based on adequate trials. Efforts to use these recommendations to control physician practice by proxy for financial gain are unethical and should be prominently noted and publicized if found to occur.

Richard A. Robbins, MD

Allen R. Thomas, MD

References

1. http://choosingwisely.org/?page_id=13
2. http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html?_r=1&permid=67
3. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
4. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
5. Hurley J, Garciaorr R, Leudy H et al. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. (Submitted)
6. http://www.abim.org/research/seminal-bibliography/certification.aspx

*The Southwest Journal of Pulmonary and Critical Care is the official publication of the Arizona Thoracic Society which is the Arizona state affiliate of the  American Thoracic Society.

The opinions expressed in this editorial are the opinions of the authors and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Reference as: Robbins RA, Thomas AR. Will fewer tests improve healthcare or profits? Southwest J Pulm Crit Care 2012;4:111-3. (Click here for a PDF version of the editorial)