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John Held, APR Select Media Coverage • • • • • • • • • • • • • • • •

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5 Medical Tests You May Not Need ABC News Carrie Gann April 4, 2012 A routine visit to the doctor's office can bring up a laundry list of medical tests, all designed to screen for one serious disease or another. But according to a new report from leading physician groups, a large number of medical tests and procedures billed as routine are largely unnecessary. "There's no medical treatment or test that is 100 percent without risk," said Dr. Christine Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation. "Things that you might think are routine actually should not be done because they expose patients to risk." To help patients parse through the barrage of medical procedures, the ABIM Foundation and Consumer Reports have created the Choosing Wisely project, a campaign that asked nine physician groups to identify five tests or procedures in their fields that are overused or unnecessary. Cassel said the project is designed to give patients as much information as doctors have about screening, as well as to rein in health care costs. The full list is published today, but here's a look at five common tests you may not need. Cardiac stress tests were once considered a staple of routine check-ups. Also called the treadmill test or an exercise EKG, doctors often use it to determine if a patient has blocked arteries. The U.S. Preventive Services Task Force has long recommended that people at low risk for cardiovascular disease and with no symptoms of heart trouble don't need an annual stress test. But a 2010 Consumer Reports survey of 8,000 people ages 40 to 60 found that 44 percent of low-risk people with no symptoms had been screened. "In the late 1990s, the concept of the executive physical became popular - this included a stress test and battery of labs and other tests that would be repeated annually no matter what the previous year's results, and everyone wanted to be considered as good as an executive," said Dr. Carolyn Eaton, a family physician in San Antonio. "I often will explain to middle aged patients that no, they don't need a stress test." A basic exercise EKG costs about $200. Some doctors use a nuclear stress test in which a radioactive dye illuminates how well the heart is working. Those tests are priced at an average of $630. According to the American College of Cardiology, stress tests should only be performed on patients who have peripheral artery disease, diabetics over age 40 and people who have an increased risk of coronary artery disease. For many years, chest x-rays were another nuts-and-bolts part of hospital care. "It was just what you did. You came to the hospital and got a chest x-ray," said Dr. Paul Larson, a spokesman for the American College of Radiology. But the test is going by the wayside. The American College of Radiology said for most patients undergoing outpatient procedures, the tests are unnecessary.

Some people should get a chest x-ray before going under the knife, such as those with a history of heart problems, lung disease or cancer. For others with a normal physical exam, the ACR said the test leads to a change in patient care in only 2 percent of cases. A standard chest x-ray costs about $44, fairly cheap compared with other medical price tags. "But as we're trying to control health care costs in general, it's an example of things that aren't really necessary," Larson said. According to the American Academy of Family Physicians, lower back pain is the fifth most common reason for all visits to the doctor's office. But unless a patient has certain red flags of a deeper physical problem, such as spinal abnormalities or neurological problems, the AAFP and the American College of Physicians say doctors shouldn't use MRIs, CT scans or other imaging to investigate lower back pain. Dr. Lee Green, a professor of family medicine at the University of Michigan, said that can be a tough answer to a patient dealing with pain that can last for an average of three to six weeks. "After two weeks, people are pretty sick of it, and they want something done about it," Green said. "To say the alternative is not to do anything is psychologically a very unsatisfying answer." The alternatives may also be unsatisfying for patients who are seeking a fast, easy solution. Green said a person's best bet for fighting lower back pain is usually to keep moving and wait for the problem to get better. But there is no evidence that imaging helps doctors solve a patient's lower back problem. At an average cost of $815 for a spine MRI, doctors say all the tests do is increase health care costs. Colonoscopies, perhaps the most unloved cancer screening, are a necessary aspect of health care after age 50. A recent study found that having precancerous growths spotted on colonoscopies removed cut the death rate from colon cancer by 53 percent. Most major medical groups recommend that people over 50 get a colonoscopy every 10 years. However, the key is moderation. According to the American Gastroenterological Association, most adults who are at an average risk of colon cancer and who get a clean bill of health from a colonoscopy don't need another one for the next decade – good news for health care pocketbooks, since the test costs an average of $1,050. Eaton said the recommendation will probably be welcome news to most patients. "Most people don't want one colonoscopy, let alone another sooner than needed," Eaton said. Osteoporosis becomes a real risk for people, particularly women, with increasing age. The National Institutes of Health estimates that one in five women over age 50 has osteoporosis. But patients may want to ask their doctors how often they r need a bone density scan to screen for signs of the disease. The American Academy of Family Physicians echoes the U.S. Preventive Services Task Force in recommending that only women over age 65 get a bone mineral density test, called dual-energy x-ray absorptiometry, or a DEXA scan. The AAFP also recommends the test for men age 70 and older, although the USPSTF said there is insufficient evidence to balance the risks and benefits of screening men for osteoporosis. The test costs more than $100, and unless a woman under age 65 has additional risk factors, such as smoking, an eating disorder or previous broken bones, doctors say the scan is unnecessary. "Once osteoporosis is identified with a DEXA scan, you do not need to have the scan every year," Dr. Ranit Mishori, assistant professor in the department of family medicine at Georgetown University School of Medicine in Washington, D.C., told ABC News. "This is a total waste of money." A study published in February found that low-risk women who have a healthy initial scan can wait up to 15 years for a repeat scan.

Associated Press Boston ER Doctor Leads “Choose Wisely” Effort October 14, 2013 BOSTON (AP) — A Boston emergency room doctor is among the leaders of a group that worked to reverse a decision by the American College of Emergency Physicians not to embrace a national campaign to reduce medical costs. Dozens of medical specialty groups have embraced the "Choosing Wisely" campaign, which asks doctors to reduce unneeded tests and procedures. A past president of the group said that the ER college declined to participate because the tests were often ordered by other doctors and because of the concern over legal action. The Boston Globe ( ) reports that on Monday, the ER college released a list of five routinely-performed tests and procedures that patients often do not need. Instrumental in this reversal was Dr. Jeremiah Schuur, a Brigham and Women's Hospital emergency physician.

Doctors unveil “Choosing Wisely� campaign to cut unnecessary medical tests CBS News Ryan Jaslow July 26, 2013 Doctors from nine of the top medical societies in the country are warning patients and fellow doctors to choose wisely when it comes to 45 common medical tests. 5 medical tests that could save your life (and 5 to skip) Some doctors may be used to prescribing these seemingly "routine tests," but the "Choosing Wisely" initiative from the American Board of Internal Medicine Foundation says these procedures are often unnecessary and besides driving up the country's skyrocketing health care costs, can put patients at risk. According to The New York Times, up to one-third of the $2 trillion of annual U.S. health care costs is spent on unnecessary hospitalizations and tests, ineffective new drugs and medical devices, unproven treatments, and unnecessary end of life care. Nine leading medical specialty societies, including the American College of Cardiology and the American Society of Clinical Oncology , created lists of "Five Things Physicians and Patients Should Question." Along with ABIM, they're teaming up with the world's largest independent product-testing group, Consumer Reports, to spread the word that patients and doctors alike should stop and say "wait a second" at their next doctor visit. "Today these societies have shown tremendous leadership in starting a long overdue and important conversation between physicians and patients about what care is really needed," Dr. Christine K. Cassel, president and CEO of the ABIM Foundation, said in a written statement. "Physicians, working together with patients, can help ensure the right care is delivered at the right time for the right patient. We hope the lists released today kick off important conversations between patients and their physicians to help them choose wisely about their health care." The evidence is on the initiative's side. A 2010 Consumer Reports survey of 1,200 healthy adults showed that almost 50 percent of them had received screening tests for heart disease that were considered "very unlikely or unlikely to have benefits that outweigh the risks." A study in a September 2011 issue of the Archives of Internal Medicine found 80 percent of surveyed doctors said they order some tests that may not be necessary out of fear they might get sued for malpractice, HealthPopreported. "I would say most doctors probably feel somewhat helpless when they're expected to practice defensive medicine and check off a whole bunch of boxes," Dr. Calvin Chou, a professor of medicine at the University of California, San Francisco, said at the time. What tests should patients question? The American Gastroenterological Association says for colon cancer screening, low-risk patients (who don't have a family history) should not repeat screening for 10 years after a high-quality colonoscopy comes back negative. The American

Academy of Allergy, Asthma & Immunology says physicians shouldn't order a CT-scan or "indiscriminately prescribe antibiotics" for sinus infections. "We're not saying they should never be done, we're saying these are often unnecessary, and therefore the patients should ask the doctor, 'Gee, do I need this?'" Cassel told the Wall Street Journal. The complete lists of all 45 things doctors and patients should question can be found here. The initiative's backing by top medical societies may mean it's more likely to alter treatment standards, experts said. "Overuse is one of the most serious crises in American medicine," Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the project, told the New York Times. "Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message."

ACEP's Campaign to Reduce Uneccessary Testing in the Emergency Department Forbes Robert Glatter October 16, 2013 At the opening session of their annual gathering in Seattle on October 14, the American College of Emergency Physicians (ACEP) released a list of five tests and procedures which may not be cost effective in certain clinical situations, hoping to spark a discussion with patients and their medical providers that may reduce inappropriate ordering of tests, imaging and performance of procedures in the emergency department (ED) when appropriate. The goal is to improve patient care, while also reducing overall healthcare costs. “Emergency physicians are dedicated to improving emergency care and to reducing health care costs,” said Alex Rosenau, DO, FACEP, president of ACEP. “These recommendations are evidence-based and developed with significant input from experts”. These recommendations are a symbol of ACEP’s participation in the ABIM Foundation’s “Choosing Wisely” campaign, an effort over the past several years to help encourage a dialogue among patients and physicians to optimize the delivery of testing and procedures, and to avoid certain treatments when harm may exceed any potential benefit. The “Choosing Wisely” campaign, which launched in April 2012, now includes more than 80 national, state as well as regional medical specialty societies. ACEP joined the campaign in February 2013. ACEP had previously decided not to participate in the campaign, mainly out of concern that emergency medicine is inherently different than office-based medical care with respect to evaluation of patients, but also regarding the lack of medical liability reform as part of the principles of the campaign. “Overuse of medical tests is a serious problem, and health care reform is incomplete without medical liability reform, ” said Dr. Rosenau. He added, “Millions of dollars in defensive medicine are driving up the costs of health care for everyone. We will continue to encourage the ABIM Foundation and its many partners in this campaign to lend their influential voices to the need for medical liability reform.” ACEP’s five recommendations were developed from input from the ACEP Board of Directors, as well as research and ideas from an expert panel of emergency physicians. In 2012, ACEP selected Dr. David Ross, an EMS Director in Colorado to chair a Cost Effectiveness Task Force to reach out to survey all ACEP members. “ACEP needed a strategy to determine what emergency physicians could do to improve efficiency and reduce cost without affecting the quality of care we deliver,” said Dr. Ross. He added, “The challenge also was to identify real cost savings, but also to develop consensus among emergency physicians.”

Five “Choosing Wisely� recommendations endorsed by the ACEP Board of Directors: 1. Avoiding CT scans of the head in patients in the emergency department with minor head injury who are already at low risk based on validated decision rules. The bulk of minor head injures do not result in intracranial bleeding or skull fractures, which require a CT scan for definitive diagnosis. 2. Avoiding placement of indwelling urinary catheters in the emergency department for the purpose of monitoring urinary output in stable patients who can urinate on their own. 3. Avoiding delays in involving hospice and palliative care services in the emergency department for patients who may derive benefit. Early referral for such services may result in better quality and quantity of life. 4. Avoiding antibiotics and wound cultures in patients in the emergency department with uncomplicated skin and soft tissue abscesses after a successful incision and drainage procedure with adequate medical follow-up. Opening the abscess and providing drainage is the definitive treatment in an uncomplicated scenario, and antibiotics offer no further benefit in the absence of surrounding cellulitis or fever. 5. Avoiding intravenous (IV) fluids, prior to a trial of oral rehydration, in children with mild to moderate dehydration. To minimize possible complications and pain, it is ideal to administer fluids by mouth as opposed to using an IV in children who are awake and alert and can tolerate oral fluids.

Choosing Wisely Targets 90 More Dubious Tests, Therapies Medscape Robert Lowes February 21, 2013 Seventeen medical societies today released a list of almost 90 common but often unnecessary tests and procedures, many of them ordered for a peculiar kind of patient — the one without symptoms. No fewer than 12 of the guidelines issued as part of the "Choosing Wisely" campaign of the American Board of Internal Medicine Foundation caution physicians that asymptomatic patients probably do not need a given treatment. A few examples follow, along with the society that recommended them: • Don't screen for carotid artery stenosis in asymptomatic adult patients (American

Academy of Family Physicians). • Don't automatically use computed tomography scans to evaluate children's minor head

injuries (American Academy of Pediatrics). • When prescribing medication for most people aged 65 years and older who have type 2

diabetes, avoid attempting to achieve tight glycemic control (American Geriatrics Society). • Don't routinely order imaging tests for patients without symptoms or signs of significant

eye disease (American Academy of Ophthalmology). • Don't screen for ovarian cancer in asymptomatic women at average risk (American

College of Obstetricians and Gynecologists). • Avoid using stress echocardiograms on asymptomatic patients who meet "low-risk"

scoring criteria for coronary disease (American Society of Echocardiography). American Board of Internal Medicine President Christine Cassel, MD, said such rules of thumb seek to change the mindset in physicians and patients alike that "more is better," which leads to wasteful spending and sometimes puts the patient at risk. "What you're talking about is a culture change," Dr. Cassel told Medscape Medical News. In April 2012, the Choosing Wisely campaign released 5 guidelines apiece from 9 medical specialties. One of those societies, the American Academy of Family Physicians, has released an additional 5 guidelines in this year's batch. The Society of Hospital Medicine, making its Choosing Wisely debut in 2013, also issued 5 guidelines for adult inpatient care and another 5 for pediatric inpatient care. The 2013 guidelines from all 17 societies total 90 guidelines, but one appears in the list both from the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. That guideline cautions physicians not to schedule elective, nonmedically

indicated induction of labor or cesarean deliveries before 39 weeks and zero days of gestational age. As it did last year, the watchdog organization Consumer Reports is working with other consumer-oriented groups such as AARP, the Leapfrog Group, and the National Partnership for Women & Families, as well as Wikipedia, to spread the Choosing Wisely guidelines to patients. This public outreach seeks to educate Americans that not every test and procedure is appropriate for a particular condition, said William Zoghbi, MD, president of the American College of Cardiology, which released its list of 5 last year. "Sometimes patients request a treatment they don't need," Dr. Zoghbi told Medscape Medical News. "It takes much longer to dissuade a patient from asking for test than actually ordering the test." More information on Choosing Wisely is available on the initiative's Web site.

Doctor Panels Recommend Fewer Tests for Patients New York Times Roni Caryn Rabin April 4, 2012 In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often. The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States. “Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.” Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace. Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests. The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine and in partnership with Consumer Reports. The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common. The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease. Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family. Other efforts to limit testing for patients have provoked backlashes. 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. “Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.” Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.” 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. Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation. Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients. “These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.” Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease. “I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.” Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately. “It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done

EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

Doctors’ Bad Habits New York Times Daneille Ofri October 5, 2013 RECENTLY I was talking with a patient about her glucose levels, which have been inching their way toward diabetes. She was honest that she was eating too much junk and knew perfectly well that her diet was not doing her health any favors. We talked about the circumstances of her daily life, and together came up with the plan: she would try to eat one fruit or vegetable every day, while cutting out one serving of junk food. It was a modest goal, but seemed obtainable. A perfect example of shared decision making. But after she left, I glanced back at my previous notes and saw that we’d negotiated the exact same compromise during her last appointment. Scrolling back, I could see that at every visit we covered the same nutritional territory, and each time I must have congratulated myself on the excellent patient-centered care. Unfortunately, it wasn’t getting us anywhere. Her diet hadn’t budged. We doctors constantly lament how difficult it is get our patients to change their behavior. We rant about those who won’t take their meds, who won’t quit smoking, who never exercise. But the truth is, we are equally intransigent when it comes to changing our own behaviors as caregivers. Clinical practice guidelines are a common way of summarizing the standard recommendations for medical conditions. There are thousands of guidelines, for everything from genetic screening to bedsore prevention. Most doctors and nurses think that well-researched guidelines are an excellent idea. Most agree with their recommendations. The problem is, most of us are just like our patients — we often ignore good advice when it conflicts with what we’ve always done. I thought about this as I read the latest recommendations from the Choosing Wisely campaign — a project led by the American Board of Internal Medicine to inform doctors and patients about overused and ineffective tests and treatments. Medical groups were asked to list five things in their field that are often overutilized but don’t offer much benefit.

Last month, my specialty group — the Society of General Internal Medicine — released its Choosing Wisely recommendations. No. 2 was: “Don’t perform routine general health checks for asymptomatic adults.” This runs counter to a basic pillar in medicine that doctors and patients remain strongly attached to: the annual checkup. This is our chance to do screening tests and vaccinations and to discuss a healthy lifestyle. Anecdotally, we all can cite examples of checkups that uncovered serious illness. But the scientific evidence shows that on balance, the harm of annual visits — overdiagnosis, overtreatment, excess costs — can outweigh the benefits. Yet, I still do them. Each time I see a healthy patient, I close the visit by saying, “See you in a year.” It’s a reflex. After the research was initially published last year, I grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit, if only because it establishes a solid doctor-patient relationship. But seeing these new, strongly worded recommendations, I may have to re-evaluate. At the very least, I should take a moment to think before I reflexively recommend the annual visit. But I know that I might still end up doing the same thing, despite the evidence. Humans are creatures of habit. Our default is to continue on the path we’ve always trod. If we doctors can recognize that impulse in ourselves, it will give us a dose of empathy for our patients, who are struggling with the same challenges when it comes to changing behavior. Danielle Ofri is an associate professor at New York University School of Medicine, the editor of the Bellevue Literary Review and the author of “What Doctors Feel: How Emotions Affect the Practice of Medicine.”

Doctors Urge Their Colleagues to Quit Doing Worthless Tests NPR Richard Knox April 4, 2012 Nine national medical groups are launching a campaign called Choosing Wisely to get U.S. doctors to back off on 45 diagnostic tests, procedures and treatments that often may do patients no good. Many involve imaging tests such as CT scans, MRIs and X-rays. Stop doing them, the groups say, for most cases of back pain, or on patients who come into the emergency room with a headache or after a fainting spell, or just because somebody's about to undergo surgery. A child with low belly pain and suspected appendicitis? Don't rush her to the CT scanner. Do an ultrasound first. That will give the answer 94 percent of the time, is cheaper and doesn't expose the child to radiation. Don't put heartburn patients on high doses of acid-suppressing drugs when lower doses and shorter courses will do, they say. You might just be making their symptoms worse when they try to stop the medicine. An apparently healthy middle-aged guy with few cardiac risk factors comes in for a yearly exam and wants to know how his ticker is. Don't give him a full cardiac workup, with a treadmill test and fancy imaging. This kind of patient accounts for almost half of unnecessary cardiac screening. Postpone repeat colonoscopies for 10 years if the first one is negative, or if it found and removed one or two early-stage colon polyps, the guidelines state. And stop prescribing antibiotics for mild-to-moderate sinus infections. And here's one that raises some tricky questions: Most patients who are debilitated with advanced cancer shouldn't get more chemotherapy. "When somebody is literally bed-bound and unable to walk or take care of himself, it's almost futile to use cancer-directed treatment and will probably have negative consequences," says Dr. Lowell Schnipper, a Boston cancer specialist who helped develop the new guidelines. Schnipper tells Shots many cancer patients are getting chemotherapy in the last weeks of their lives. He says that does no good, makes patients miserable and may shorten their life. The Choosing Wisely project was launched last year by the foundation of the American Board of Internal Medicine. It recruited nine medical specialty societies representing more than 376,000 physicians to come up with five common tests or procedures "whose necessity ... should be questioned and discussed." The groups represent family physicians, cardiologists, radiologists, gastroenterologists, oncologists, kidney specialists and specialists in allergy, asthma and immunology and nuclear cardiology.

Eight more specialty groups will join the campaign this fall, representing hospice doctors, head and neck specialists, arthritis doctors, geriatricians, pathologists, hospital practitioners, nuclear medicine specialist and those who perform a heart test called echocardiography. Consumer groups are involved, too. Led by Consumer Reports, they include the AARP, National Business Coalition on Health, the Wikipedia community and eight others. The effort represents a growing sense that there's a lot of waste in U.S. health care, and that many tests and treatments are not only unnecessary but harmful. Harvard economist David Cutler estimates that a third of what this country spends on health care could safely be dispensed with. "That's certainly the number we use," Dr. Steven Weinberger, CEO of the American College of Physicians, tells Shots. "Most of us feel something like $750 billion or so could be eliminated from the system out of the $2.5 trillion or so that we spend on health care." Weinberger says unneeded diagnostic tests probably account for $250 billion. "I talk about this a fair amount around the country, and invariably physicians come up to me and recount their own anecdotes about overuse and misuse of care," he says. Proponents of the campaign are aware they're wading into dangerous waters. "There will be some ... that may demonize this campaign and infer the R-word — rationing," Daniel Wolfson of the ABIM Foundation wrote in December when the campaign was launched. But rationing is the denial of care that patients need, Wolfson points out. The Choosing Wisely campaign aims to reduce care that has no value.

Medical Waste: 90 More Dont's For Your Doctor NPR Richard Knox February 21, 2013 Doctors do stuff — tests, procedures, drug regimens and operations. It's what they're trained to do, what they're paid to do and often what they fear not doing. So it's pretty significant that a broad array of medical groups is issuing an expanding list of don'ts for physicians. Don't induce labor or perform a cesarean section for a baby who's less than full term unless there's a valid medical reason, say the American College of Obstetrics and Gynecology and the American Academy of Family Physicians. (It can increase the risk of learning disabilities and respiratory problems.) Don't automatically do a CT scan on a child with a minor head injury, warns the American Academy of Pediatrics. (Currently half of all such children get them, when simple observation is just as good and spares radiation risk.) Don't try to normalize blood sugar in most diabetic patients over 65, exhorts the American Geriatrics Society. (It can lead to higher mortality rates.) And on and on. The latest totals 90 tests and procedures that are often unnecessary and potentially harmful, compiled by 17 specialty groups representing more than 350,000 doctors. The list is the second chapter in a campaign called Choosing Wisely sponsored by the . Last year the foundation against 45 tests, procedures and treatments that often do patients no good. That list was endorsed by nine medical specialty organizations. The new don'ts bring the total to 135. The idea is to curb unnecessary, wasteful and often harmful care, its sponsors say — not to ration care. As one foundation official , rationing is denial of care that patients need, while the Choosing Wisely campaign aims to reduce care that has no value. The campaign aims to foster the notion, among patients as well as doctors, "that when it comes to health care, more is not necessarily better," Dr. of the ABIM Foundation says in a statement abut the latest list, to be officially unveiled at a Washington media event Thursday. The sponsors promise even more lists of don'ts later this year from a dozen more specialty groups, ranging from the American College of Surgeons to the American Headache Society. Here are some other notable tests, traditions and procedures to skip:

Don't use feeding tubes in patients with advanced dementia. Simply assisting such patients to take food by mouth is better. Don't perform EEGs (electroencephalography) on patients with recurrent headaches. It doesn't improve diagnosis or outcomes and simply increases costs. Don't perform routine annual Pap tests in women between 30 and 65. Every three years is enough. Don't hold back on providing palliative care to relieve pain and distress just because a seriously ill patient is getting treatment aimed at alleviating disease. Don't leave an implantable defibrillator turned on if a patient with incurable disease, or his family decision-makers, have elected to forgo resuscitation. Currently there are no formal policies on this issue, and implantable defibrillators often fire in the weeks preceding death, causing pain and distress to dying patients and their families. Don't use cough and cold medicines in children under 4 suffering from respiratory illness. They offer little benefit, can have serious side effects and risk accidental overdose. Don't do repeat bone scans for osteoporosis more often than every two years. Healthy women over 67 with normal bone mass can go up to 10 years without a repeat bone scan. Don't prescribe benzodiazepines, such as Valium, or sedatives and sleep aids to older adults with insomnia, agitation or delirium. They can more than double the risk of motor vehicle accidents, falls, hip fractures and death. Don't screen patients routinely for vitamin D deficiency. Over-the-counter supplements without laboratory testing is sufficient for most otherwise healthy patients. Don't screen for cancer in healthy individuals using CT or PET scans. The likelihood of finding cancer is around 1 percent, and the scans are likely to leading to more tests, biopsies or needless surgery.

Just Say Don't: Doctors question routine tests and treatments Reuters Sharon Begley February 21, 2013 Now there are 135. That's how many medical tests, treatments and other procedures - many used for decades physicians have now identified as almost always unnecessary and often harmful, and which doctors and patients should therefore avoid or at least seriously question. The lists of procedures, released on Thursday by the professional societies of 17 medical specialties ranging from neurology and ophthalmology to thoracic surgery, are part of a campaign called Choosing Wisely. Organized by the American Board of Internal Medicine's foundation, it aims to get doctors to stop performing useless procedures and spread the word to patients that some don't help and might hurt. "Americans' view of healthcare is that more is better," said Dr Glenn Stream, a family physician in Spokane, Washington, and board chairman of the American Academy of Family Physicians, which has identified 10 unnecessary procedures. "But there are a lot of things that are done frequently but don't contribute to people's health and may be harmful." In a particular case, even a procedure that provides no benefit to the vast majority of people might be appropriate. That's why the physicians emphasize that they are only advising against routine use of the usually unnecessary tests and therapies. For instance, the American Academy of Pediatrics says physicians "should question" CT scans for kids' minor head injuries or abdominal pains, which usually don't improve diagnoses and raise the risk of cancer. But if doctors suspect something unusual, a scan may be in order. For the most part, the medical specialty groups did not consider cost when they made their lists. If their advice is followed, however, it would save billions of dollars a year in wasteful spending, said Dr John Santa, director of Consumer Reports' Health Ratings Center and a partner in Choosing Wisely. One large medical group with 300,000 patients, Santa said, calculated that following the Choosing Wisely advice on just two procedures, superfluous EKGs (electrocardiograms) and bone-density scans, would reduce its billings by $1 million a year. Nationally, that translates into some $1 billion in savings. The medical specialty groups each came up with five procedures to "question," but most of the items begin with an emphatic "don't." The targeted procedures range from the common to the esoteric. RETHINKING SWIMMER'S EAR, PRE-OP TESTS

Other specialists say no cough and cold medications for kids under 4, no oral antibiotics for acute infections of the ear canal ("swimmer's ear") and no use of drugs to keep blood sugar in older adults with type 2 diabetes within tight limits. There is no evidence that tight "glycemic control" - which is widely practiced - is beneficial, said the American Geriatrics Society. Instead, the diabetes drugs used to achieve tight control increase mortality, and tight control itself can cause low blood sugar. Some recommendations, if widely adopted, would mean significant changes in patient care. The geriatricians, for example, recommend against feeding tubes in patients with advanced dementia. The tubes hurt and cause problems; carefully feeding the patient is better. Anyone who has ever had surgery while in generally good health can sympathize with the recommendation against multiple pre-op tests: Ophthalmologists now advise against EKGs and blood glucose measurements before eye surgery, except for patients with heart disease or diabetes. Physicians recommend against many procedures patients have come to expect, including imaging for low back pain (unless it has lasted more than six weeks) and any cardiac screening, including EKGs, in patients without heart symptoms. The widely used "DEXA" X-ray screening for osteoporosis landed in rheumatologists' crosshairs. It should not be done more than once every two years, they advise, because changes in bone density over shorter periods are typically less than the machines' measurement error, which can cause women to think they're losing bone mass when they're not. RETREAT FROM DEFCON Other "don't's" may be hard sells to patients for whom any abnormality requires medicine's version of Defcon 1. Take a finding of abnormal cells in the cervix. The American College of Obstetricians and Gynecologists (ACOG) says not to treat women whose Pap test for cervical cancer finds dysplasia unless the abnormalities persist for two years. "Treatment damages the cervix and raises the risk in subsequent pregnancies," said ACOG Executive Vice President Dr Hal Lawrence. The abnormal cells are almost always the result of a viral infection that the body clears on its own, but women who think they mean impending cervical cancer will need convincing. If doctors adopt the recommendations of their specialty, doctor visits for some chronic diseases would be very different. Patients with recurrent headaches would not get EEGs (electroencephalography); they don't improve outcomes. And rheumatologists would not use MRIs to monitor joints in patients with rheumatoid arthritis; a clinical assessment is just as good. Women in particular would get quite different care. Those younger than 21 and those who have had a hysterectomy for anything but cancer should not get Pap smears at all, experts say. Other women should get the tests every three years, not annually, between ages 30 to 65.

"We did a great job training everyone, women as well as doctors, to get an annual Pap smear," said ACOG's Lawrence. "Now we have to untrain them." That won't be easy. The first Choosing Wisely list of 45 procedures was released last April, too recently for there to be hard data on whether they're changing practice. But some of these battles have been fought for years, with scant success. ACOG has been trying to reduce the rate of elective cesareans for decades, and its Choosing Wisely list tells obstetricians not to schedule elective cesareans or induce labor before week 39. The rate of cesareans in the United States was 33 percent of deliveries in 2009, up from 21 percent in 1996, federal data show. WORSE FOR BABIES, BETTER FOR REVENUES The experience of Intermountain Healthcare, a group of hospitals and clinics in Utah, suggests why. The nonprofit recently cut its rate of inappropriate labor inductions and cesareans from 28 percent of births to 2 percent. That saved Utah $50 million a year in healthcare spending, mostly by reducing use of the neonatal intensive care unit, where many babies delivered in these ways wind up. But Intermountain also lost $9 million in annual billings. "In our fee-for-service healthcare system," said Consumer Reports' Santa, "poor clinical outcomes for babies improve revenue streams for hospitals," and better care can reduce revenues. Many business groups have signed on to Choosing Wisely, hoping it will reduce soaring healthcare costs. For instance, the National Business Coalition on Health, with 7,000 employer members, and the National Business Group on Health, representing Fortune 500 companies and other large employers, are distributing to their members educational material developed by Consumer Reports, a partner in Choosing Wisely. They are careful to emphasize that the advice comes from doctors. "If employers say you shouldn't have all these tests or procedures, it'll inevitably be seen as 'my employer doesn't want to spend the money to cover them,'" said Helen Darling, president of the Business Group. The pages and pages of lists raise an obvious question: How did so many worthless and even dangerous procedures become so widely used? For one thing, there is no regulatory requirement that physicians prove a new procedure helps patients, as drug makers must do before selling a new pharmaceutical. For another, "Americans want the latest, newest thing," said Dr Howard Brody of the University of Texas Medical Branch, whose 2010 challenge to physicians to identify worthless tests and treatments inspired Choosing Wisely. "Technological enthusiasm on the part of physicians and the general public makes them willing to adopt new things without rigorous testing. Only years later, and only if studies are done, do we see that it's no good."

Physicians Groups Call for Fewer Tests for Patients Time Magazine Alice Park April 5, 2012 Nine professional medical societies are calling on doctors and patients to cut back on unnecessary tests and procedures. Question is, Are they listening? If you feel you’re poked, prodded and subjected to too many tests when you visit the doctor, your physician may actually agree. Nine major medical societies, including the American College of Cardiology and the American Society of Clinical Oncology have banded together — representing nearly 375,000 physicians — to promote Choosing Wisely, an initiative aimed at getting doctors to perform 45 commonly used tests and procedures less often and patients to start questioning their doctors about the procedures they’re offered. The coalition of professional groups, working under the auspices of the American Board of Internal Medicine Foundation, is urging doctors to stop overusing medicine. Many doctors order tests even if they might not be necessary and may even harm the patient, sometimes to protect themselves from potential lawsuits, sometimes because the tests are simply profitable for the physician. The move is a bold one and, while not binding, it’s a first step toward acknowledging and reining in medical overspending. A large chunk of rising health care costs in the U.S. is due to excessive and unnecessary medical care: some experts say that as much as one-third of our annual $2 trillion in health care spending goes to unneeded tests and hospitalizations, along with unproven and ineffective treatments and heroic but futile end-of-life therapies, according to the New York Times. Each of the nine professional groups has come up with five tests or procedures that it believes doctors and patients overuse routinely (see here for the full list). The American Gastroenterological Association, for example, is recommending against repeat colonoscopies within 10 years of a normal result from a first colonoscopy for patients with no family history of colon cancer. The American College of Physicians is advising against using MRI to image patients any time they complain of generalized low back pain, and heart experts say doctors should stop using stress echocardiograms in routine check-ups for patients who don’t have chest pain or other risk factors for heart disease or heart attack. “We’re not saying they should never be done, we’re saying these are often unnecessary, and therefore the patients should ask the doctor, ‘Gee, do I need this?’” Dr. Christine Cassel, CEO of ABIM, told the Wall Street Journal. Other procedures the groups are urging against: prescribing antibiotics for sinus infections, ordering imaging scans for patients with simple headaches, and treating cancer in end-stage patients who have not responded to other therapies and aren’t eligible for experimental treatments.

The trick is drawing the line between excessive care and appropriate care, which many doctors say has become exceedingly difficult in our litigious society. The more-is-better mentality largely arises from a health care system in which doctors can be sued for malpractice if they make a misdiagnosis or omit certain services. And until that changes, say some, the habit of ordering tests — just to be safe — will be hard to break.

Coalition of Medical Societies Urges Questioning Treatments USA Today Nanci Hellmich April 4, 2012 Physicians and patients should question some commonly used tests and treatments that often are unnecessary and costly and may in some cases be harmful, says a report out today that's part of a new campaign to improve care and cut waste. Some of the recommendations have been around, but the campaign represents a rare coordinated effort among multiple medical societies. Nine leading physician specialty societies — including the American Academy of Family Physicians, the American College of Cardiology and the American College of Physicians — each identified five procedures, treatments and tests (for a total of 45) that the groups say are routinely used but may not always be necessary. Their lists are being released today as part of the ABIM (American Board of Internal Medicine) Foundation's Choosing Wisely campaign (, which is being done in conjunction with Consumer Reports magazine. For instance, the American College of Radiology says people don't need routine chest X-rays before surgery if the patient has an "unremarkable" medical history and physical exam. One goal of the campaign is to make people "feel empowered to go to their doctor and say, 'Do I really need this test?'" says Christine Cassel, president of the ABIM and the group's foundation. John Santa, an internist and the director of the Health Ratings Center for Consumer Reports, says, "I think it's courageous of cardiologists, internists and family physicians to suggest reducing services that they know generate income for some of their members. I'm sure some of their members won't be happy." Among the campaign's advice to physicians and patients: • Don't do imaging for lower back pain within the first six weeks unless there are red flags, such as decreased strength in a leg, says the American Academy of Family Physicians. It does not improve outcomes but does increase costs. • There's no need to repeat colorectal cancer screening for 10 years if a high-quality colonoscopy comes back negative in average-risk individuals, the American Gastroenterological Association says. • Don't routinely prescribe antibiotics for acute mild-to-moderate sinus infection unless symptoms last for seven or more days, the American Academy of Family Physicians says. Most sinusitis is due to a viral infection and will resolve on its own. • Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors, the family physicians group says. • Don't obtain a stress test or treadmill test for individuals who have no symptoms of heart troubles and are at low risk for coronary heart disease, the American College of Physicians says. The report's release was not timed to coincide with the current Supreme Court debate on healthcare legislation, Cassel says. "But we live in the same world. We all know we are paying too

much on health care. If we can cut some of our costs, then we can have enough resources to provide health care for those who need it." Sidney Wolfe, an internist and director of the health research group at Public Citizen, a consumer group, was not involved in creating the new campaign. But he says it is "identifying unnecessary, overused tests. Unnecessary tests frequently lead to unnecessary surgery or unnecessary drugs being prescribed, which can lead to unnecessary injuries, unnecessary surgeries and unnecessary deaths."

PSA test part of trend: Fewer screenings for well people USA Today Liz Szabo May 29, 2012 Yet health experts say the recommendations by the U.S. Preventive Services Task Force are a part of a broader trend that's been building for years. People are taking a closer look not just at cancer screenings, but at all medical tests and procedures, says Steven Woloshin, co-director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice. Concern about "overtesting" and "overtreating" patients is growing because of a rising recognition that these interventions often have risks and serious side effects. "There is something going on, not just in cancer," Woloshin says. "There is some sort of shift, and it's encouraging. It feels like this is the beginning of a sea change in attitudes towards testing, treating and overdiagnosis." Doctors are taking a "less is more" approach on several fronts. Last month, for example, nine physicians' groups launched the "Choosing Wisely" campaign to discourage 45 frequently overused tests and procedures. The groups, which included the American College of Cardiology, noted many common interventions are unnecessary, including stress tests during routine annual exams. Many of these overused tests involve trying to "help the well stay well by looking for things to be wrong," says H. Gilbert Welch, a physician and author of Overdiagnosed: Making People Sick in the Pursuit of Health. The American College of Radiology also is leading campaigns called Image Wisely, to reduce unnecessary radiation exposure in adults, and Image Gently, to reduce exposure in children. The campaigns address growing concerns over the risk of cancers related to medical radiation, which has been estimated to cause up to 29,000 cancers a year. Researchers estimate that one-third of CT scans may be unnecessary, according to a 2009 report in the Archives in Internal Medicine. And in the past four years, medical groups have voted to restrict several types of cancer screenings. That's partly because science has evolved to help doctors better understand how cancers progress and how best to use screening technology, and also because doctors better understand the risks and limitations of treatment, says Lisa Schwartz, also co-director at the Dartmouth Center. • In 2008, for example, before the task force voted against the PSA entirely, it recommended offering it only to men under age 75, reasoning that older men would not likely be helped by a test that largely detects slow-growing cancers. • In 2009, the task force recommended against routine mammograms for women under 50, and suggested women over 50 get screened every other year, instead of annually. That recommendation drew fierce protests from women, radiologists and many politicians. • In March, in a less controversial move, the American Cancer Society revised its cervical cancer recommendations, suggesting that women get screened every three years, instead of every year,

between the ages of 21 and 29. Older women can wait five years between tests, and stop screening at age 65, a change that reflects the slow-growing nature of these tumors. • Last week , medical groups endorsed using CT scans to screen for lung cancer, but only in a very specific group: smokers and ex-smokers ages 55 to 74 who smoked the equivalent of a pack a day for 30 years, and who still smoke or quit within the past 15 years. Younger people, or those who smoked less, are not advised to get screened for lung cancer, because the odds of being harmed by the test — which can lead to invasive lung biopsies — is so high, and the chance of being helped is much lower, says Peter Bach, director of Memorial Sloan-Kettering's Center for Health Policy and Outcomes, who wrote an analysis of available evidence published May 20 in the Journal of the American Medical Association. Bach says it was important to avoid repeating past mistakes. With other screening tests, medical organizations have recommended them broadly for everyone in a particular age category — often before studies showed they did what they were intended to do. The PSA was approved in 1986 to monitor patients with diagnosed prostate cancer, and in 1994 to screen healthy men — before researchers had determined whether the tests improved survival. For years, many medical groups recommended the PSA for all men over 50. "The PSA test was unleashed on the male population without any evidence that it provides any benefit and without any quantification of the potential harm," Bach says. "We didn't realize we would cause thousands of men to become impotent." Yet convincing people that they could be better off with fewer screenings could be a tough sell, says Virginia Moyer, chair of the U.S. Preventive Services Task Force and a pediatrician at the Baylor College of Medicine. Public health groups spent decades persuading reluctant men to give blood samples for PSA tests and frightened women to get their breasts compressed by mammography machines. Today, many people see screening as essential to health, she says. And the science of screening — and the reasons why it can harm — aren't easily boiled down into a soundbite. "We've been a victim of our own success," Moyer says. But Welch, the physician and author, agrees the tide is turning. There's a growing recognition that, "when you are dealing with well people, the balance is really fine: It's hard to make a well person better, but it isn't hard to make them worse," says Welch. "We need to have really high thresholds before we start doing things to well people."

Many Medical Tests and Procedures Aren’t Needed — Doctors’ Groups Wall Street Journal Anne Wilde Matthews April 4, 2012 Many medical tests and procedures are performed when they aren’t needed, a new campaign by several doctors’ groups says. The initiative, coordinated by the foundation affiliated with the American Board of Internal Medicine, will initially focus on 45 medical services — five each produced by nine different doctor-specialty societies. It will later add future lists from other specialties. The lists will be publicized by Consumers Union’s Consumer Reports, AARP and other consumer groups, says Dr. Christine Cassel, the foundation’s CEO. “We’re not saying they should never be done, we’re saying these are often unnecessary, and therefore the patients should ask the doctor, ‘Gee, do I need this?’” Cassel tells the Health Blog. The campaign, dubbed “Choosing Wisely,” comes amid intense pressure to rein in growing health-care costs. Doctors are trying to take the initiative from insurers. “We’re better positioned to do this than insurance companies,” Cassel says. Many of the examples on the initial lists, such as imaging scans, focus on services and situations that have long drawn concern about overuse. The American Society of Nuclear Cardiology noted several circumstances in which cardiac imaging wasn’t typically necessary. For instance, it said, patients with chest pain who are at low risk of cardiac death or a heart attack don’t typically need stress echocardiography. The American College of Radiology said doctors often shouldn’t do imaging for uncomplicated headaches. The American College of Physicians said imaging studies aren’t usually needed for non-specific lower-back pain. Some of the suggestions may spark debate. The American Academy of Family Physicians says antibiotics shouldn’t routinely be initially prescribed for acute mild or moderate sinus infections. Yet doctors say they often come under pressure from patients with sinus symptoms who want to be prescribed antibiotics. Likely to be touchier is the recommendation from the American Society of Clinical Oncology that doctors should typically steer away from chemotherapy or radiation therapy for patients with solid tumors who aren’t doing well, don’t qualify for a research trial, haven’t responded to multiple past treatments and show no strong evidence that they will benefit from new ones. Instead, such patients may do better with palliative care aimed at easing their pain and other symptoms, says Dr. Lowell Schnipper, the chairman of the society’s task force on the cost of cancer care and a professor at Harvard Medical School.

Doctors Groups Call for End to Unnecessary Procedures Washington Post Brian Vastag April 4, 2012 Among the tangled factors sending U.S. health-care costs soaring, unnecessary tests and procedures rank high on the list. A 2005 National Academy of Sciences report found that 30 percent of U.S. health-care spending was unnecessary or wasteful; more recent studies arrive at similar figures. That amounts to a staggering $600 billion to $700 billion spent annually on tests, drugs and procedures that most likely do no good — and can do harm. Patients and caregivers are both to blame, of course. Patients ask for medicines or procedures they’ve heard about, even if they’re inappropriate for their situation; and doctors, worried about being sued, often practice “defensive medicine,” ordering procedures to prevent lawsuits, not because it’s good medicine. To help push down these buried costs, nine doctors groups on Wednesday released a list of 45 common tests or procedures that consumers and doctors should think twice about before asking for — or ordering. The new “Choosing Wisely” campaign, sponsored by the American Board of Internal Medicine Foundation, aims to get doctors and patients talking about these 45 procedures to achieve “better decision making.” Here are some of the tests, medicines and procedures that “should be questioned”: • Antibiotics for sinus infections: The vast majority of infections are not caused by bacteria • X-rays for low back pain: Unnecessary unless “red flags” signify possible serious disease • Stress tests for healthy people: Heart screening tests don’t make sense unless the patient has diabetes or other heart risk factors • CT or MRI head scans for fainting: Unnecessary unless signs of a seizure are also present • CT scans for appendicitis in children: Less expensive ultrasound scans are preferred • Repeat colonoscopies within 10 years: For those at low to average risk for colon cancer, once a decade is enough • PET, CT, bone scans to determine spread of early prostate and breast cancers: If tumors are low grade — meaning they present a low risk of metastasis — scans can lead to unnecessary surgery, radiation and chemotherapy. The doctors’ groups are partnering with Consumer Reports, AARP and 10 other consumer groups to get out their message. The entire list of 45 (often) unnecessary tests and procedures is online at -

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