We’ve been champions of the Choosing Wisely campaign, an initiative by several medical specialties to call out procedures they advise doctors and patients to view with skepticism. But now it looks like there's a big "Not in My Back Yard" problem with the program.
Last year, for example, our blog “Orthopedic Treatments You Should Reject” outlined five treatments the American Academy of Orthopaedic Surgeons said appeared to have little worth.
So it’s disappointing to realize, as a story by KaiserHealthNews and the Chicago Tribune recounted last week, that some of the largest medical associations participating in Choosing Wisely tabbed rare treatments or those performed by practitioners in other fields instead of those that are lucrative for them. "They were willing to throw someone else’s services into the arena, but not their own," said Dr. Nancy Morden, whose research into the societies’ advice was published in the New England Journal of Medicine.
The campaign was a welcome change in a medical profession that historically had been reluctant to spurn unnecessary treatments, often because they are money-makers for the practitioners. Of course, that also means they add costs for patients and insurers, aren’t proved to improve health and sometimes can cause harm.
Since 2012, 54 specialty societies in Choosing Wisely have recommended procedures to avoid, and the lists have been distributed to more than half a million doctors. Hospitals that use them report diminishing use of unnecessary procedures.
And Morden’s study did find that some specialty pointed the finger at their own indulgences — gastroenterologists, radiologists and clinical pathologists among them. For example, as our blog reported, the Society of General Internal Medicine advised against getting an annual physical exam.
Other medical specialties said they hadn’t included their own procedures if the concerns about them were about overuse, because in some cases, for some patients, they are appropriate, such as stents for heart patients and spine surgery, two procedures we have advised patients to scrutinize very closely before undergoing.
Those societies tended to focus on limiting testing that others do. Morden, a researcher at the Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire, examined everything named on the first 26 Choosing Wisely lists. More than 8 in 10 targeted radiology, medications and cardiac and lab tests — not physician services.
The American College of Cardiology included the use of cardiac testing in four circumstances, but didn’t address what scientific evidence indicates is the most frequent type of overtreatment in the field — implanting stents, which are small tubes used to prop open arteries of patients who are not suffering heart attacks. More measured, and often more successful treatments for potential heart problems, are prescribing certain medicines and making changes in lifestyle.
KHN/Tribune refers to a study showing that as many as 1 in 8 stent procedures should not have been performed, and at hospitals where stenting was most overused, about 6 in 10 stents were deemed inappropriate.
But, as one cardiologist told KHN/Tribune, "Let's face it, angioplasty and stenting is a big business, it's highly profitable for hospitals, and it's highly remunerative for physicians. There's a tremendous impetus to not rock the boat and not to call attention to the fact that we do too many procedures in stable patients for whom outcomes would be the same if not even better if treated medically."
Orthopedics is another specialty whose Choosing Wisely recommendations protected its members’ interests but not necessarily those of patients and insurers. The American Academy of Orthopaedic Surgeons discouraged patients with joint pain from taking certain dietary supplements, from using custom shoe inserts or overusing wrist splints after carpal tunnel surgery and from a procedure some doctors use to bathe an aching knee in a saline wash.
Although the advice to spare yourself the cost of glucosamine supplements is good, the loss of that commerce doesn’t affect doctors. And the knee saline injections are seldom done anyway. When Morden reviewed 2011 Medicare billing records for the procedure, she found "zero claims."
"That's how pathetic that item is," she told KHN/Tribune.
One orthopedic surgeon nominated other, more significant procedures he told the reporters were overused but were not on the Choosing Wisely lists, including replacing hips and knees when the patient’s pain is minimal and can be managed with medicine, and surgically inserting metal plates into broken collarbones, rather than letting the injury heal with the help of a sling.
"The abuse of surgery is due to the overwhelming control of the profession by the implant manufacturing companies," he told KHN/Tribune.
Being a spine surgeon is a lucrative profession: According to one survey, the median compensation is more than $730,000 per year, so it might seem upstanding that the North American Spine Society included a procedure using bone growth material for neck fusion on its “avoid” list. But it’s not clear how many spine surgeons even perform it anymore. The FDA issued a safety alert against the procedure it in 2008 because it could cause the neck to swell, compress airways and make breathing and speaking difficult.
This group’s members didn’t mention spinal fusion, which more than doubled in frequency between 1998 and 2008, according to one study. Patients with back pain are more likely to be referred to another physician, probably for things like injections and surgery, instead of physical therapy, which usually should be the first line of treatment.
As the KHN/Tribune story notes, “where the lists have been actively embraced, the rate of those services has dropped. Last year, the Cedars-Sinai Health System in Los Angeles added 120 Choosing Wisely recommendations into its computerized patient records so that they would pop up on a screen whenever a clinician tried to authorize one.”
The use of benzodiazepines and other sedative-hypnotics to treat the elderly have decreased at Cedar-Sinai as a result of Choosing Wisely recommendations by the American Geriatrics Society. That’s good, because these drugs can cause elderly patients to fall.
At Anne Arundel Medical Center in Annapolis, "Choosing Wisely" lists are broadcast on hospital television screens, posters decorate the walls of doctors' offices and the lists are included in communications mailed to county residents. The lists also are embedded as links in electronic patient records so physicians can easily review them.
Those are all excellent measures as far as they go, but as the NEJM study suggests, they just don’t go far enough.