NOW there are 135. That’s how many medical tests‚ treatments and other procedures — many used for decades — doctors 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 by the professional societies of 17 medical specialties in the US‚ ranging from neurology and ophthalmology to thoracic surgery‚ are part of a campaign called Choosing Wisely.
Organised 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.
Many people’s view of healthcare is that "more is better”‚ says Dr Glenn Stream‚ a family physician in Spokane‚ Washington‚ and board chairwoman 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‚ however. That’s why the physicians emphasise that they are only advising against routine use of the usually unnecessary tests and therapies.
For instance‚ the American Academy of Paediatrics says doctors "should question” CT scans for children’s 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‚ says Dr John Santa‚ director of Consumer Reports’ Health Ratings Centre and a partner in Choosing Wisely.
One large medical group with 300‚000 patients‚ Dr Santa says‚ calculated that following the Choosing Wisely advice on just two procedures‚ superfluous electrocardiograms (ECGs) and bone-density scans‚ would reduce its billings by $1m a year. Nationally‚ that translates into about $1bn in savings.
The medical specialty groups each came up with five procedures to "question” but most of the items began 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 children under four‚ 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 "glycaemic control” — which is widely practised in South Africa — is beneficial‚ says 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 sympathise with the recommendation against multiple pre-op tests: ophthalmologists now advise against ECGs 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 lower-back pain (unless it has lasted more than six weeks) and any cardiac screening‚ including ECGs‚ in patients without heart symptoms.
The widely used "DEXA” X-ray screening for osteoporosis landed in rheumatologists’ cross hairs. 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 items on the "don’t” list 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 Gynaecologists 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‚” says the college’s 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 an EEG‚ or electroencephalography; they don’t improve outcomes. And rheumatologists would not use MRIs‚ or magnetic resonance imaging‚ 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 and 65.
"We did a great job training everyone‚ women as well as doctors‚ to get an annual Pap smear‚” says Dr 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.
The American College of Obstetricians and Gynaecologists has been trying to reduce the rate of elective caesarians for decades‚ and its Choosing Wisely list tells obstetricians not to schedule elective caesarians or induce labour before week 39. The rate of caesarians in the US was 33% of deliveries in 2009‚ up from 21% in 1996‚ federal data show.
Caesar rates have also climbed in South Africa in recent years‚ so much so that the country now has one of the highest elective caesarians rates in the world.
Worse for babies‚ better for revenue
The experience of Intermountain Healthcare‚ a group of hospitals and clinics in Utah‚ suggests why. The nonprofit organisation recently cut its rate of inappropriate labour inductions and caesarians from 28% of births to 2%. That saved Utah $50m 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 $9m in annual billings.
"In our fee-for-service healthcare system‚” says Consumer Reports’ Dr Santa‚ "poor clinical outcomes for babies improve revenue streams for hospitals‚” and better care can reduce revenue.
Many business groups have signed on to Choosing Wisely‚ hoping it will reduce soaring healthcare costs. For instance‚ the US National Business Council 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.
They are careful to emphasise 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‚’” says 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‚ in the US‚ as in South Africa and other countries‚ there is no regulatory requirement that doctors have to prove a new procedure helps patients‚ as drug makers must do before selling a new pharmaceutical.
For another‚ many people just "want the latest‚ newest thing”‚ says 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 (doctors) 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.”
Reuters‚ with Marika Sboros