Dr. Christine Cassel, President & CEO of the ABIM Foundation

“We all know that we live in a healthcare system that is very costly and in which there is a lot of waste,” stated Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM) Foundation. The question is what to do about it?

Cassel, who is board certified in internal medicine and specializes in geriatrics, said the ABIM Foundation is focused on professionalism, quality of care, and the physician’s complex role in today’s delivery environment. “In particular, the last couple of years has been focused on the stewardship of resources,” she said.

In fact, “Promoting Good Stewardship in Medicine,” a project of the National Physicians Alliance (NPA), was funded by the ABIM Foundation to identify five areas where primary care providers could deliver high quality care while conserving resources. “Top Five” lists of overused diagnostic tests, procedures and treatments were created in conjunction with the primary care societies for internal medicine, family medicine and pediatrics and included items such as not ordering an annual ECG or other cardiac screening for asymptomatic, low-risk patients and avoiding the pressure to prescribe antibiotics for pharyngitis unless the patient tested positive for streptococcus.

The well-received lists were published last year in the Archives of Internal Medicine. Coming off that success, Cassel said the idea was launched to expand the ‘five things’ to additional medical specialties and to partner with Consumer Reports and other key consumer advocacy groups. The medical societies, she pointed out, had the research and data to pinpoint tests and procedures being overused without the necessary evidence to back up the orders, and the consumer organizations could help translate that information into a patient-friendly format.

“Research shows 30 percent of the time, physicians order these tests because the patient wants it. It puts doctors in a very uncomfortable role. That’s why it’s so important for patients to have the same information,” she said. “We’re not saying you should never do these things,” Cassel stressed. “We’re saying these are common areas of overuse so this is something you and your doctor should have a conversation about.”

In April, nine specialty societies representing nearly 375,000 physicians and 11 consumer-oriented organizations joined ABIM Foundation and Consumer Reports in the Choosing Wisely campaign – “Five Things Physicians and Patients Should Question.”

As opposed to the government or an insurance company suggesting cutting back on tests, procedures or treatments, which could be construed as rationing, these lists have been hailed by patient advocates as a significant step toward improving the quality, safety and cost of healthcare.

“It’s the right message with the right messengers … doctors and patients together,” said Cassel. “It’s personalized medicine. It’s not ‘one size fits all.’”

Cassel, who spent 25 years practicing in academic settings before taking her current role more than eight years ago, said it was important to note that most every test, every procedure has some side effect. If a CT scan is warranted, the radiation dose is extremely small in comparison to the valuable information provided. If, however, the evidence doesn’t support the use of CT, then the bottom line is that a patient is being unnecessarily exposed to radiation.

She noted the reasons for overuse are multifactorial and include the practice of defensive medicine, patient requests for a treatment or test, the fee-for-service structure of the nation’s current reimbursement system, and what she called the ‘rituals of medicine.’ Cassel added it is easy for physicians to get in a routine of practicing a certain way without being aware of the latest research that might point in a different direction.

She applauded the willingness of physicians and their allied societies to reevaluate practice patterns even though stopping overuse could impact the bottom line. “I think it demonstrates physicians really do want to do the right thing even if it means a potential loss of revenue,” she said.

Cassel added these lists fit well with the movement away from the fee-for-service model and toward the delivery of evidence-based medicine with increased engagement of patients in their own care. Delivering the right care at the right time for the right patient, she concluded, is the epitome of high value, cost conscious care.

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Who Has Signed On

Medical Societies: Lists Released

American Academy of Allergy, Asthma & Immunology

American Academy of Family Physicians

American College of Cardiology

American College of Physicians

American College of Radiology

American Gastroenterological Association

American Society of Clinical Oncology

American Society of Nephrology

American Society of Nuclear Cardiology

Medical Societies: Lists to be Released Fall 2012

American Academy of Hospice and Palliative Medicine

American Academy of Otolaryngology – Head and Neck Surgery

American College of Rheumatology

American Geriatrics Society

American Society for Clinical Pathology

American Society for Echocardiography

Society of Hospital Medicine

Society of Nuclear Medicine

Consumer Organizations

AARP

Alliance Health Networks

Leapfrog Group

Midwest Business Group on Health

National Business Coalition on Health

National Business Group on Health

National Center for Farmworker Health

National Partnership for Women & Families

Pacific Business Group on Health

Service Employees International Union (SEIU)

Wikipedia (through the dedicated community Wikipedian in Residence)

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Should You or Shouldn’t You

Finding five tests, procedures or treatments to evaluate before ordering was a simple task for the participating medical societies. In fact, the American College of Physicians has actually found more than 30 items that should come off the autopilot list as part of its own High Value, Cost-Conscious Care Initiative (www.acponline.org). Below is a sample of findings from the Choosing Wisely campaign.

§       American College of Physicians: Do patients need brain imaging scans like CT or MRI after fainting? Probably not. Research has shown that without evidence of seizure or other neurologic symptoms during an exam, patient outcomes are not improved with these imaging studies.

§       American Society of Nephrology: Should you administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia? Administering ESAs to CKD patients with the goal of normalizing hemoglobin levels has no demonstrated survival or cardiovascular disease benefit and could be harmful in comparison to a treatment regimen that delays ESA administration or sets relatively conservative targets (9–11 g/dL).

§       American College of Radiology: Should patients going into outpatient surgery receive a chest x-ray beforehand? If the patient has an unremarkable history and physical exam, then the answer is ‘no.’ Most of the time these images will not result in a change in management and have not been shown to improve outcomes.

§       American Academy of Family Physicians: Should women under 65 or men under 70 be screened for osteoporosis with dual energy x-ray absorptiometry? No, research has shown that in the absence of risk factors, DEXA screening is not helpful in this age group.

§       American Academy of Allergy, Asthma & Immunology: Should you routinely perform diagnostic testing in patients with chronic urticaria? Probably not. In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing might be warranted to exclude underlying causes, and targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes.