The Choosing Wisely initiative, announced last week by the American Board of Internal Medicine Foundation, aims to spark conversation among both doctors and their patients about the types of tests and treatments that are likely to be unnecessary, and perhaps even harmful. More tests, the group explains, does not always mean better care – and overuse of these diagnostics is a huge contributor to the United States’ surging medical costs.
Among the potentially unnecessary tests being highlighted by the effort, which pulls together specialty organizations representing physicians who treat everything from cancer to allergies: EKGs or other routine cardiac screening for low-risk patients with no symptoms, CT scans for children suspected of having appendicitis or adults who’ve fainted and don’t have any other red flags for serious problems, and routine follow-up testing for certain breast cancer patients. The New York Times called the new effort "sound medicine and sound economics."
The issue of overtesting is a special challenge for emergency physicians. Most of the time, patients are unknown to them, and sometimes, unconscious or otherwise too sick to explain their symptoms or medical history. That often means starting from scratch with determining what might be wrong, and making calls to their previous physicians doesn’t always yield answers, especially during off hours. “In the ER, I have to be more cautious because I have no doctor-patient relationship to rely on. I have no baseline for my patients,” says Dr. Judd Hollander, the director of clinical research for Penn’s department of Emergency Medicine, who studies emergency care cost containment issues.
And, patients may not actually be aware of the details of their past care or tests. One study, for instance, found that among abdominal pain patients asked whether or not they’d ever had a CT scan before, 40 percent of those who said “no” actually had at least one such test noted in their electronic medical record. Hollander also notes that physicians often report test results only in terms of immediate action items. If, for instance, an ultrasound to examine a patient’s gallbladder doesn’t reveal enough of a problem to require surgery, the patient might be told they’re all clear – when, in fact, they may have small gallstones that could eventually progress to the point of causing dangerous symptoms. If that same patient goes to an emergency room months later with severe abdominal pain, they won’t have all the information they need to help their new doctor make decisions about the possible cause of their condition.
Some of the top reasons people head to emergency rooms – abdominal pain, chest pain and headaches – are all issues that can be caused by a vast range of problems, from those that can be fixed with a single dose of an over-the-counter drug to those that could prove life-threatening within hours. Is it indigestion or an aortic aneurysm about to rupture? A bout of GI distress from lunch off a food truck, or an ectopic pregnancy? A migraine headache or a brain tumor?
As Penn's Dr. Zachary Meisel explained last year in a column on Time.com, this complex diagnostic face-off plays a huge role in why emergency physicians tend to lean heavily on tests like CT scans, even though they expose patients to radiation and there are few clear guidelines on which patients should get them. Most patients with these common symptoms won’t be in any immediate danger if they’re sent home without absolute certainty of the cause of their distress, but a small number could die in their beds hours later. Patients, understandably, demand assurance they’re not in that group. As Hollander noted last month when discussing the results of his trial examining the use of CT angiography to rule heart attacks among ER patients with chest pain, “When you come the emergency department, you’re not really going to Las Vegas – you don’t really just want to hope for the best and roll the dice. You want to go home knowing that you don’t have a serious problem, and if you do have a serious problem, you want to get it taken care of. It’s a high-risk situation; we can’t afford to be wrong.”
Even in areas where there’s firm, research-based guidelines about which diagnostics to use, patients may request specific tests by name, perhaps because they’ve seen ads for a new imaging technology or read a story in the media about, say, cancer biomarker tests that aren’t yet ready for widespread clinical use. “It’s virtually impossible to explain to ER patients why they don’t need a particular test they’ve heard about,” Hollander says. “Patients don’t care about the societal costs of over testing, they care individually – they want to know, ‘Is there any chance anything will ever be missed on me?’”
That’s especially true for patients with health insurance, who typically won’t pay for much, at all, of their tests since they’ve already funded that coverage through their premiums. The physical costs of overtesting, too, usually remain hidden from view: To a patient who’s scared and in pain in the middle of the night, the idea that unclear or positive results of one test may require another, perhaps more invasive, test that will ultimately turn up negative doesn’t have much sway. By partnering with Consumer Reports and organizations like the AARP and the service union giant SEIU, the Choosing Wisely initiative aims to educate patients about these issues long before they actually need to worry about them.
Ongoing research and new features in Penn’s electronic medical record may guide some of these conversations, too -- and help physicians feel more confident about limiting tests. Dr. Angela Mills, the medical director of HUP’s Emergency Department, is spearheading an effort to reduce overutilization of CT scans for abdominal pain through a new “decision support” tool embedded within a patient’s electronic medical record.
“For many patients, like those who are older or have cancer, it might not make a difference,” Mills said, “but there is a good subset of patients who are younger, healthier, and who have things that are usually not life-threatening like kidney stones, for whom we are hoping this will reduce their exposure to unnecessary radiation.”
Each time an ER physician orders a scan for abdominal pain, the tool walks them through a series of questions that serve as checks and balances for their decision to order the test. They’re queried, for instance, on what diagnosis they’re trying to look for (from appendicitis to colitis to an ovarian cyst or tumor), and how likely they think it is that the patient actually has that problem. It also provides information on how many different abdominal imaging tests the patient has previously had at Penn, and tallies their total radiation exposure from previous CT scans – perhaps prompting the care team to rethink their choice of tests.