"Choosing Wisely" Highlights Opportunities to Improve Utilization by Cutting Waste

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Radiologists can play a key part in helping referring physicians concentrate on areas where they can eliminate financial waste and unnecessary testing, says an ACR fellow who worked on the American Board of Internal Medicine Foundation Choosing Wisely campaign.

“We’re trying to make patients and physicians comfortable with the idea that having more tests is not always the best way,” says Debra Monticciolo, MD, FACR. “This is a good start to look at the cost of healthcare and see where we can really help.”

Monticciolo is vice-chair of the ACR Commission on Quality and Safety, vice-chair for research in the radiology department at Texas A &M University. Aside from highlighting the overall collegiality of radiologists, she says Choosing Wisely underscored how deeply practice issues identified by the eight other specialty groups were influenced by imaging.

“A lot of this is imaging,” she says. “We expect that; diagnosis of patients involves imaging. We have to take charge, and that’s the reason the American Board of Medicine got so many other subspecialties on board. Let’s show people that we really can have the patient’s best interests in mind, [and] maybe we can get rid of some expensive tests.”

Monticciolo says the intention of Choosing Wisely is to initiate a dialogue among specialists, referring physicians, and their patient groups to take a more informed interest in treatment where non-specific, non-acute issues are involved—the common complaints that can account for waste in terms of volume and redundancy in terms of treatment.

“It’s something that the ACR was excited to be involved with [because] it goes along with our longstanding commitment to extensive appropriateness criteria and what tests should be done when,” she says.

The panel determined whether a commonly prescribed procedure is unnecessary based on research about treatment outcomes and the associated impact of time, money, and other resources in performing these exams. They found:

• With no evidence of seizure or other neurologic symptoms, CT or MRI scans after fainting spells do not improve health outcomes.

• Healthy adults free of cardiac symptoms don’t necessarily need stress imaging tests at annual checkups: according to the American College of Cardiology, “These tests rarely result in any meaningful change in patient management.”

• Outpatient surgery patients don’t necessarily need a chest x-ray beforehand if they have an unremarkable history. “When I was an intern you always got a chest x-ray on everybody,” Monticiollo says. “That’s just what you did. It turns out that the times that you find something it’s less than 2% of the time.”

• Prescriptions of CT scans or antibiotics for chronic sinusitis may not be necessary; most acute rhinosinusitis issues resolve within two weeks with no treatment required.

• Routine cancer screening tests do not help symptom-free dialysis patients with limited life expectancies, and can even cause stressful false positives.

• Dual-energy x-ray absorptiometry (DEXA) screenings aren’t helpful for senior patients who are free of risk factors.

The defining characteristic of these procedures involves their relative commonality and the relative familiarity among physicians about the handling of such issues.

“Chest x-ray is a low-cost, low exposure [procedure], but they’re done a lot,” Monticiollo says. “If you do one on everybody that comes into the hospital or has day surgery, the impact just grows because of the volume. We didn’t want this to be things where people throw these away and say, ‘I don’t do that.’”

Again, Monticiollo explains, the focus of Choosing Wisely is in establishing a dialogue to resolve such issues. As a breast imager, she says she finds that her patients are generally more informed these days than ever before, and they’re not afraid to ask questions of their doctors and have these types of conversations. She hopes that the strength of a cosigner like Consumer Reports will further strengthen the impact of their findings.

“A little knowledge can be problematic, but that said, we want to put information out there so there is accurate information out there,” Monticiollo says. “We’re working to distill our recommendations into lay language for the patient.