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Medical experts: Doctors should think twice before ordering these 90 tests, procedures

A feeding tube. One of 90 tests and procedures that medical societies implored doctors to think twice about was using feeding tubes in patients with dementia.
A feeding tube. One of 90 tests and procedures that medical societies implored doctors to think twice about was using feeding tubes in patients with dementia.

A campaign sponsored by the American Board of Internal Medicine (ABIM) has released a list of 90 medical procedures and tests that health providers shouldn't perform in certain situations.

The Choosing Wisely campaign "is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances cause harm."

In other words, the initiative is looking to cut back on worthless care – the overuse of tests and procedures – that in some cases could harm the same patients it's trying to help.

Why so many tests and procedures?

Unnecessary procedures aren't usually something patients in the safety net have to worry about, said Nina Vaccaro, the executive director of the Southside Coalition of Community Health Clinics.

That's because providers who serve that population already ration care.

"It's not perhaps the best way provide medicine, but it's really the only option that we have," said Vaccaro. "You're not going to do an expensive diagnostic test of a patient unless they truly need it. That's not a luxury community clinic physicians have – to just order every test under the sun to make sure you've covered all your bases."

Cutting back on the tests saves resources so people who actually need them can get them, she said.

The cost of tests can add up, especially if they're not covered by insurance plans. But it's not necessarily patients racking up costs and "abusing the system," said Vaccaro.

"[Doctors] may very well know we don't need to run this test, we don't need to do that [electrocardiogram]," she said. "But I think more often than not, it's done because it's available. Patients want to make sure they're getting every single test possible."

Physicians, in turn, will order those tests because they fear they're "opening themselves up to be sued for malpractice if they miss something," said Vaccaro.

Other tests are covered by insurance. But insurance companies find ways to recover their costs, and that could mean higher premiums for coverage or coverage denials.

Vaccaro said health care reform is cracking down on those sort of measures, which has prompted some insurance companies to refuse covering certain tests and procedures.

The list

In April, the ABIM's campaign released a list of 45 common medical procedures and tests that doctors should think twice about before ordering. The list includes multiple colonoscopies within 10 years for an average-risk patient and imaging tests for "non-specific low back pain."

That was the result of the campaign meeting with nine leading physician specialty societies, representing nearly 374,000 physicians across the U.S.

Now, the ABIM says there are 38 specialty medical societies on the campaign, which have collectively released 90 more procedures and tests that they say aren't always necessary.

Here's a sampling:

From the American Academy of Family Physicians: Don’t perform Pap smears on women who are 1) younger than 21, or 2) have had a hysterectomy for a disease that isn't cancer.

Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.

From the American Academy of Hospice and Palliative Medicine: Don’t recommend feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding.

In advanced dementia, studies have found feeding tubes do not result in improved survival, prevention of aspiration pneumonia, or improved healing of pressure ulcers. … In the final phase of this disease, assisted feeding may focus on comfort and human interaction more than nutritional goals.

From the American Academy of Neurology: Don’t use opioid or butalbital treatments for migraine headaches except as a last resort.

Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments.

From the American Academy of Pediatrics: Cough and cold medicines shouldn't be prescribed or recommended for respiratory illnesses in children younger than four.

Research has shown these products offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.

From the American College of Rheumatology: Don’t perform an MRI of a patient's peripheral joints to routinely monitor inflammatory arthritis.

Data evaluating MRI for the diagnosis and prognosis of rheumatoid arthritis are currently inadequate to justify widespread use of this technology for these purposes in clinical practice.

From the American Society for Clinical Pathology: Don't test for low-risk human papillomavirus (HPV) – that's the kind that causes genital warts or "very minor cell changes on the cervix."

National guidelines provide for HPV testing in patients with certain abnormal Pap smears and in other select clinical indications. The presence of high risk HPV leads to more frequent examination or more aggressive investigation (e.g., colposcopy and biopsy). There is no medical indication for low risk HPV testing … because the infection is not associated with disease progression and there is no treatment or therapy change indicated when low risk HPV is identified.

From the American Society of Echocardiography: Avoid using stress echocardiograms on patients who don't have symptoms and who meet “low risk” scoring criteria for heart disease.

There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors.

This brings the number of procedures and tests the Choosing Wisely campaign has highlighted to 135.