Two recent articles in the New York Times and USA Today take a close look at the rising costs of health care and nationwide efforts to curb unnecessary tests and procedures as a means of reducing these costs and ensuring patient safety.

"In more instances than many people realize, doing more medically can be worse than doing less," writes Jane Brody for the Times. "Too often, costly, overly aggressive medical care causes more pain and suffering than if nothing had been done at all. Our expectations and demands of health care must change, and we must reckon with the incentives for tremendous waste that are now built into the system."

According to USA Today, "concern about 'overtesting' and 'overtreating' patients is growing because of a rising recognition that these interventions often have risks and serious side effects."

In both cases, the news articles cite the efforts of the recently launched Choosing Wisely^® campaign, of which the ACC and eight other specialty societies were original partners. The overarching goal of Choosing Wisely^® is to promote wise choices by clinicians and patients in order to improve health care outcomes, provide patient-centered care that avoids unnecessary and even harmful interventions, and reduce the increasingly high cost of health care. To that end, the ACC and eight other specialty societies released evidence-based lists of tests and procedures for patients and physicians to question this past April. An additional 11 groups are expected to release additional lists in the coming months.

The ACC list, in particular, details the following five recommendations for consumers and providers to question in cardiology:

• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
• Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
• Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

The list was developed over several months, with the College asking its standing clinical councils to recommend between three and five procedures that should not be performed or should be performed more rarely and only in specific circumstances. ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the tightest inappropriate score in the AUCs and were Class III recommendations in the guidelines. The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval.

Additional lists from 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 (ASNC) are available here.

"By establishing these recommendations as standards of care, the societies reduce the risk that doing less may spur malpractice suits, which currently prompt many doctors to overtest and overtreat — so-called defensive medicine," writes Brody. Stay tuned for more information on Choosing Wisely campaign activities at www.choosingwisely.org. Read an ACC in Touch Blog post on the April launch of the campaign. In addition, check out the new patient radiation safety resource center on CardioSmart.org in partnership with ASNC.

 

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