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Choosing Wisely

Posted April 10, 2012

Consumer Reports in conjunction with the American Board of Internal Medicine have launched a campaign they have dubbed Choosing Wisely. Their web site, www.choosingwisely.org, highlights a list of five tests or procedures compiled by each nine leading physician specialty societies they indicate are commonly used in their respective fields but may be overused or unnecessary. The groups include allergists, family physicians, cardiologists, gastroenterologists, oncologists, nephrologists, radiologists, nuclear cardiologists and members of the American College of Physicians. While many of us may suspect the coming of Obamacare is prompting this scrutiny, published research over five years ago from the Harvard U. School of Public Health http://www.ncbi.nlm.nih.gov/pubmed/15928282 found 93% of high-risk physician specialists reported practicing defensive medicine. “The Dartmouth Atlas of Health Care has steadily documented the existence of geographical variations in care and demonstrated that more care does not equal better outcomes.” Click here to read in more detail http://www.managedcaremag.com/archives/0908/0908.qna_fisher.html. A research study focused on the medical care and intervention of premature infants roiled the way we have always done it in medicine by revealing that more money, more intervention, and more care does not translate to better outcomes even in the vulnerable population of high-risk infants. http://ruccs.rutgers.edu/tech_rpt/NICU_Noise_TR76.pdf Even a Business Week editorial focusing on the U.S. healthcare/disease care bill that is higher than any other country on the planet indicated more money does not equal more care and more care does not equal better care.

Even some of the most widely used mass screening tests for cancer (specifically prostate cancer, breast cancer, colon cancer) have not withstood scientific scrutiny. Gilbert Welch, MD, MPH, of Dartmouth University School of Medicine in his book “Should I Be Tested for Cancer; Probably Not and Here’s Why?” debunks that “catch it in time mentality” can help us live longer and live better. Dr. Welch effectively makes a scientific case that only family risk or genetic susceptibility along with risky lifestyle choices sets that stage for routine cancer screening. However, the American Society of Clinical Oncology in its Five Things Physicians and Patients Should Question failed to mention questioning mass cancer screening as overused or abused. Click here to read their list in its entirety. http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Quality+Care/Access+to+Cancer+Care/Cost+of+Cancer+Care

The Five Things Physicians and Patients Should Question list assembled by the American College of Cardiology as well as the other 8 lists bears additional review. Heart disease for all our advances in technology, diagnosis, and treatment remains the number one cause of death in the U.S. In 2007, the overall cost of direct care for heart disease was $164.9 billion and is estimated to have been $183 billion in 2009. To read further click on: http://healthcarecostmonitor.thehastingscenter.org/kimberlyswartz/projected-costs-of-chronic-diseases/#ixzz1rfciCctn. The list from the top group of heart doctors is as follows:

Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.  
Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events.

Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.  Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation.

Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.  Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery (e.g., cataract removal). These types of tests do not change the patient’s clinical management or outcomes and will result in increased costs.

Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.  Patients with native valve disease usually have years without symptoms before the onset of deterioration. An echocardiogram is not recommended yearly unless there is a change in clinical status.

Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).  Stent placement in a noninfarct artery during primary PCI for STEMI in a hemodynamically stable patient may lead to increased mortality and complications. While potentially beneficial in patients with hemodynamic compromise, intervention beyond the culprit lesion during primary PCI has not demonstrated benefit in clinical trials to date.

It is truly incredible to those who have watched the 5-decade mind set shift that heart disease is truly one of less than wise lifestyle habits there is no mention of the science-based lifestyle principles that according to Walter Willett, MD, MPH DrPh. Fredrick John Stare Professor of Epidemiology and Nutrition. Chair, Department of Nutrition, Harvard School of Public Health could reduce the risk of heart disease by as much as 83%. Click here to read the published research in more detail http://www.asn-online.org/press/Renal%20Week-05/pdf/9-Diet%20and%20Optimal%20Health.pdf While eliminating screening and procedures in patients with symptoms is wise and very important, think of the impact of the following:

  • Eat no bad fats
  • Eat some good fat daily
  • Eat as many fresh fruits and vegetables as possible
  • If you eat a grain, make it a whole grain
  • Eat normal protein (1 gram for every 2 pounds of body weight)
  • Get daily physical activity
  • Supplement wisely

These simple 7 steps reduced the risk of heart disease by 83% and type II diabetes by 91%. This research is published in the New England of Medicine, a publication that is recognized by each of these 9 physician groups. Over 80% of health care costs in the U.S. are related to the treatment of chronic degenerative diseases. Imagine the mind-set shift that may occur both in medicine and among consumers if there could be a consensus to teach and model these seven lifestyle steps.  Kudos to these doctor groups for taking this first baby step but let’s achieve true health care reform. It is possible minus 2700 pages and a Supreme Court challenge.

Deborah A. Ray, MT(ASCP) April 10, 2012