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主题 : Doctor Panels Recommend Fewer Tests for Patients
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级别: 新手上路
0  发表于: 2013-07-24  

Doctor Panels Recommend Fewer Tests for Patients

[size=11.5pt]In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.
The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.
“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”
Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.
Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.
The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.
The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble,M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.
The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.
Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.
Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.
“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.”
Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”
Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.
Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.
Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.
“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”
Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.
“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.”
Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.
“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”
This article has been revised to reflect the following correction:
Correction: April 5, 2012
An article on Wednesday about a move to recommend that doctors curb the use of 45 common and often unnecessary medical tests and procedures misidentified the organization that was issuing the advisory. It is the American Board of Internal Medicine Foundation, an organization that promotes physician professionalism — not the American Board of Internal Medicine, the specialty board with which it is affiliated.

Do Patients Want More Care or Less?
By DAVID NEWMAN, M.D. April 4, 2012, 4:11 pm
The woman’s wheeze was a head-turner, audible from across the emergency department. Along with a hacking cough, the musical, whistling sound prompted her to leave the children asleep with her sister one night and seek relief at the E.R.
Inhaled medicines were able to quiet her lungs, and with a clear chest X-ray and easy breathing restored, the diagnosis was simple: acute bronchitis.
While diagnosing bronchitis, a common respiratory infection, is often easy, treating the condition is more difficult. Medicines may calm the symptoms, but the only cure is time. Most notably, antibiotics, though commonly prescribed, are no better than a placebo for bronchitis. Yet discussing this can be a bit of a minefield for physicians, particularly when patients are used to antibiotics for such infections. So when I sat down to talk to my patient, I was surprised when she cut me off.
“If it’s O.K. with you” she said, wiping her nose with a tissue, “I’d like to avoid antibiotics, with all those side effects.”
An hour earlier I had cared for a violinist who struck his head (but saved his instrument) during a fall. After a neurologic examination was normal and I had sutured a small cut, he and I discussed the possibility of a CT scan to detect rare hidden injuries. We also discussed the alternative: Spend the evening with a friend and come back if symptoms appear. He chose to skip the scan.
See a trend here? So does Dr. Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking. “People are more receptive to conversations about medical interventions having both pros and cons” says Dr. Barry. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”
After decades of presuming that more health care leads to better health, public consciousness may be moving toward a leaner view.
Today, a group of nine medical specialty boards is recommending that doctors perform 45 common tests and procedures less often, and is urging patients to question these services if they are offered. The move is the latest by the medical community to acknowledge that many tests and procedures are performed unnecessarily, leading to excessive costs, false positives, additional testing and even harm to patients. By some estimates, unnecessary treatment constitutes one third of medical spending in the United States.
Dr. Barry, whose editorial on shared decision making was published last month in The New England Journal of Medicine, believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.
Dr. Barry also points to news reports that may also be shifting attitudes. In just the past year, medical headlines have coveredrecord-setting fines paid by pharmaceutical companies, the overuse of potentially carcinogenic medical radiation, medical device recalls and the rise of prescription drug deaths (which now outnumber illicit drug deaths). Even once-sacred interventions likescreening for cancer are under scrutiny, with a better understanding of both limited benefits and growing harms. That randomized trials of prostate specific antigen (PSA) testing, for instance, had shown little or no lifesaving benefit was hardly noticed until last year, when the United States Preventive Services Task Force drew attention to sexual and urinary problems and prostate biopsy complications, all common fallout from positive PSA results.
Emerging research supports the trend: The Cochrane Collaboration, a leading medical review group, last month published the results of a review of more than 20,000 patients in studies of “decision aids,” communication tools meant to prepare people for treatments by explaining potential benefits, harms and uncertainties. The studies showed that patients using decision aids more often declined interventions like surgery and cancer screening, choosing more conservative options instead. Patients also reported better communication, fewer conflicts and a better understanding of risks.
This month, physicians and experts from around the country will convene in Boston for “Avoiding Avoidable Care,” the first major medical conference to focus on the perils of unnecessary and unhelpful medical care. Dr. Vikas Saini, president of the Lown Cardiovascular Research Foundation, who with Ms. Brownlee, the author, organized the conference, described it as a response to growing scientific and social consciousness. “It’s the zeitgeist,” he says. “People from all around, including Shannon and I, felt isolated without a way to connect and grow these ideas. There is no ‘Journal of Overtreatment’ to bring these concepts and people together.”
The movement toward a more restrained view of medical care raises an obvious question: Could improved communication, informed patients and increasing health literacy help to slim down a bloated system — and improve American health? As a physician planning to attend the Boston conference, I am hopeful.
Smart decisions about health are, of course, necessarily individual. But my wheezing patient and the injured violinist arrived at wise, informed decisions about their medical care by suggesting something relatively new, and certainly revolutionary: In health care, less may be the new more.
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