April 5, 2012 -- Major medical and consumer groups are coming together to question the carte blanche use of many commonly ordered tests and procedures, including MRI for low back pain and exercise EKG tests in people with no symptoms and low risk for heart disease.
Sometimes these tests can be lifesavers. Other times they are unlikely to do anything except increase costs and anxiety and expose people to unnecessary risks.
So how do you know the difference?
To help answer this question, nine major medical groups have come up with five commonly ordered tests, procedures, or treatments in their field that are overused. The "Choose Wisely" campaign is led by Consumer Reports and the American Board of Internal Medicine (ABIM) Foundation. It aims to get the doctors and patients to think twice about certain tests in certain situations.
Questionable Tests, Procedures
So what tests and procedures should you question, and when? Here are some examples of items on the list of 45 things doctors and patients should ask about:
- Exercise stress tests during routine physicals if you are at low risk for heart disease
- Imaging tests for non-specific low back pain that can't be attributed to a disease or condition after a doctor takes your history and examines you
- Antibiotics to treat an uncomplicated sinus infection; sinus infections are mostly caused by viruses, which do not respond to antibiotics.
- Imaging tests such as a CT scan or MRI if you faint and have no other neurological symptoms
- Chest X-ray, cardiac stress test, or imaging before non-heart surgery
- Dual X-ray absorptiometry (DEXA) for osteoporosis screening if you are a woman under 65 or a man under 70 with no risk factors for osteoporosis
This is not to say that these tests or treatments are never needed, says ABIM Foundation president and CEO Christine Cassel, MD. "They are sometimes necessary and often overused," she says. "No treatment and no test, no matter how routine, is without some risk."
For example, many of the groups focused on imaging tests such as DEXA, CT scan, and MRI. All of these tests expose a person to potentially harmful radiation. "When a doctor does a physical exam and takes a thorough history, they can say, 'Maybe you should have this,' but they should not be using these as routine things for everybody."
James Fasules, MD, agrees. He is the vice president of advocacy for the American College of Cardiology (ACC) in Washington, D.C. The ACC is one of the nine medical groups involved in this campaign. "You can make a diagnosis or treat a patient without ordering an imaging test," he says.
The new recommendations are "not absolutes, but they should give you pause."
Experience counts. "Experienced physicians always have the ability to step back and say in this patient, 'We should do this,' but don't have to do it in patient after patient after patient."
Some people come to their doctor wanting tests that he or she otherwise wouldn't have ordered. The new campaign materials can also help the doctor explain why they don't need the test and have the patient understand why.
Marie Savard, MD, says tests and testing are no substitute for a thorough physical exam by a skilled doctor. She is a Philadelphia-based internist and the author of several books, including How to Save Your Own Life. "We need to go back to the days of a good physical and medical history," she says. "A lot of these tests may not be necessary for people who have no findings on a physical exam."
"I am all for being much more intelligent about our use of unnecessary and expensive tests," Savard says. "Doctors have gotten away from physical exam. It is easier to order a blood test."
Her advice? "Be your own squeaky wheel. If you know something is not right or have symptoms, discuss your concerns with your doctor and make sure they are taken seriously.
"These tests may be overused, but they have their place and can be lifesaving," she says.
Who?s Involved in the New Campaign?
The other medical groups who are part of the campaign include the American Academy of Allergy, Asthma, & Immunology, the American Academy of Family Physicians, the American College of Physicians, the American College of Radiology, the American Gastroenterological Association, the American Society of Clinical Oncology, the American Society of Nephrology, and the American Society of Nuclear Cardiology. On the consumer side, 11 groups, including the AARP, Alliance Health Networks, Leapfrog Group, Midwest Business Group on Health, and the National Business Coalition on Health, are working with Consumer Reports.
Including some of the tests and procedures mentioned above, here's a larger list, by medical specialty.
Family physicians say you probably don't need:
- Imaging tests for low back pain during the first six weeks
- Antibiotics for mild or moderate sinus infections, unless symptoms last for seven days or symptoms worsen after getting better
- The DEXA osteoporosis test if you're a woman younger than 65 or a man under 70 with no risk factors
- Pap tests if you're a woman under age 21 or a woman who had a hysterectomy for a non-cancer reason
The American College of Physicians says you probably don?t need:
- ECG tests if you don't have symptoms and are at low risk of heart disease
- Brain imaging (CT or MRI scans) if you fainted and have a normal neurological exam
- Pre-operative chest X-rays if you don't appear to need them
Cancer doctors say you probably don't need:
- Treatments aimed at eliminating solid tumors if you are weak and frail, did not benefit from previous treatments, and there's no sign more treatment will help
- PET, CT, or bone scans if you have early-stage prostate cancer with low risk of spreading
- PET, CT, or bone scans if you have early-stage breast cancer with low risk of spreading
- Biomarker tests or imaging surveillance studies if you've had curative treatment for breast cancer
Cardiologists say you probably don't need:
- Exercise stress tests if you don't have symptoms or high risk of heart disease
- Exercise stress tests or advanced imaging for routine follow-up exams if you don?t have any symptoms
Gastroenterologists say you probably don't need:
- Any more than the lowest effective dose of antacids for long-term treatment of reflux (GERD)
- Repeat colon cancer screening of any kind for 10 years after a screening colonoscopy finds no polyps or tumors
- Repeat colonoscopy for five years after having one or two small polyps removed via colonoscopy
Radiologists say you probably don't need:
- Imaging studies if you have uncomplicated headache
- Imaging studies for pulmonary embolism if you don't have suspicious findings from other tests
- CT scans in children with suspected appendicitis, until ultrasound has been considered
- Follow-up imaging studies for ovarian cysts that aren't causing a problem
Allergists say you probably don't need:
- Unproven tests -- such as IgG tests or a battery of IgE tests -- to find out what you are allergic to
- Sinus CT scans or antibiotics for uncomplicated sinus infections
- Routine extensive diagnostic testing if you have chronic hives
Expect more from the campaign in the future, says ABIM Foundation's Cassel: "There are already eight more specialties that want to be part of the second wave."