By Jordan Rau
KHN Staff Writer
APR 14, 2014
This KHN story was produced in collaboration with
the Chicago Tribune.
When America’s joint surgeons were challenged to
come up with a list of unnecessary procedures in their field, their selections
shared one thing: none significantly impacted their incomes.
The American Academy of Orthopaedic
Surgeons discouraged patients with joint pain from taking
two types of dietary supplements, wearing custom shoe inserts or overusing
wrist splints after carpal tunnel surgery. The surgeons also condemned an
infrequently performed procedure where doctors wash a pained knee
joint with saline.
Scott Weingarten, chief clinical
transformation officer at Cedars-Sinai Health System in Los Angeles, says his
hospital has embraced the Choosing Wisely recommendations by adding them to the
computerized patient record system. When doctors order something on the list,
they are warned by the computer about the procedure (Photo by Jeff Lewis/AP
Images).
"They could have chosen many surgical
procedures that are commonly done, where evidence has shown over the years that
they don't work or where they're being done with no evidence," said Dr.
James Rickert, an assistant professor of orthopedic surgery at Indiana
University. "They chose stuff of no material consequence that nobody
really does."
The medical profession has historically been
reluctant to condemn unwarranted but often lucrative tests and treatments that
can rack up costs to patients but not improve their health and can sometimes
hurt them. But in 2012, medical specialty societies began publishing lists of at least five
services that both doctors and patients should consider skeptically. So far, 54
specialty societies have each offered recommendations and distributed them
to more than a half-million doctors.
Hospitals that have deployed the lists,
including Cedars-Sinai Medical Center in Los Angeles, report that the frequency
of superfluous procedures has dropped. Consumer Reports, AARP and Univision are
some of the influential organizations that have been part of a broad campaign
to educate patients about the questionable items. Dr. Donald Berwick, a former
head of Medicare, heralded the
"Choosing Wisely" campaign as
"a game-changer" because the "advice comes not from payers or
politicos, but from pedigreed physician groups."
Yet some of the largest medical associations
selected rare services or ones that are done by practitioners in other fields
and will not affect their earnings. "They were willing to throw someone else’s services into the
arena, but not their own," said Dr. Nancy Morden, a researcher at
the Dartmouth Institute for Health Policy & Clinical Practice in New
Hampshire.
Some specialists did target their own money-makers.
Gastroenterologists, radiologists and clinical pathologists all placed their
own tests on their lists. The Society of General Internal Medicine recommended
against the annual physical exam, a mainstay of American health care.
Other specialty groups said they did not include
their own procedures where there are concerns of overuse, such as stents for
heart patients and spine surgery, because the evidence is murky and the
procedures are right for some patients. "What we did when we made up the
list was to start with more straightforward situations and hopefully expand
that later," said Dr. F. Todd Wetzel, a member of the board of directors
of the North American Spine Society.
Those societies tended to focus on limiting testing
that others do. In an article in the New England
Journal of Medicine, Morden examined all the items on the first 26 Choosing
Wisely lists. She found that 83 percent of the items targeted radiology,
medications and cardiac and lab tests—not physician services.
Stenting Gets A Pass
The American College of Cardiology opted to list
the use of cardiac testing in four circumstances. But the college did not
tackle what studies suggest is the most frequent type of overtreatment in the
field: inserting small mesh tubes called stents to prop open arteries of
patients who are not suffering heart attacks, rather than first prescribing
medicine or encouraging a healthier lifestyle. As many as one out of
eight of these stent procedures should not have been performed, according to a study in Circulation,
the journal of the American Heart Association. At hospitals where
stenting was most overused, 59 percent of stents were inappropriate, the study
found.
"Let's face it, angioplasty and stenting is a
big business, it's highly profitable for hospitals, and it's highly
remunerative for physicians," said Dr. William Boden, a New York
cardiologist who oversaw the first large trials that found no advantage for
stents for patients who are not in acute distress. "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."
Dr. William Zoghbi, a Houston cardiologist who was
president of the college when the list was announced in 2012, rejected the
suggestion that stenting procedures should have been more broadly questioned,
saying "the vast majority" of stents "are quite appropriate for
the condition." He said cautious choices for the initial list made
sense because a campaign like Choosing Wisely is unfamiliar to doctors.
"You have to walk before you run," Zoghbi said.
The cardiologists did discourage one specific use
of stenting, where doctors opening a clogged artery place additional stents in
other places where screenings have spotted the starts of blockage. Dr. Vikas
Saini, a Massachusetts cardiologist and president of the Lown Institute, which
advocates for more restraint in treatments, said, "in 20 years of practice
that’s not something I would have thought is standard and if people are still
doing it, that’s a shame."
Stents are a profit center for the group of cardiologists
who perform procedures, often known as invasive cardiologists. They earned a
median salary of $488,000, according to the Medical Group Management
Association. Orthopedic surgeons do even better: half earned more than $538,000
in 2012, according to the MGMA’s income survey.
The orthopedic academy defended its Choosing Wisely
selections, writing in a statement that "our recommendations are limited
by the existing evidence regarding the effectiveness of various treatment
options for musculoskeletal conditions, which we are seeking to
improve." It noted that its recommendation against the dietary supplements
could save patients $750 million a year spent on these drugs.
The
orthopedists' selections did not impress critics. Rickert, the Indiana
orthopedist, noted that discouraging dietary supplements affects revenue for
health stores and other retail outlets, not surgeons. Both he and Morden said saline injections to treat knee
pain are seldom done. Morden said when she searched 2011 Medicare billing
records for the procedure, "I found zero claims."
"That's
how pathetic that item is," she said.
Dr. Augusto Sarmiento, a former president of the
academy and retired chairman of orthopedics at the University of Miami Miller
Medical School, said there
were more significant overused procedures the academy omitted, including
replacing hips and knees when the patient’s pain is minimal and can be managed
with medicine.
In addition, Sarmiento said too many surgeons operate on simple fractured collarbones, inserting metal plates, 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 said.
Spinal Fusions Spared
The median compensation of a spine surgeon is more
than $730,000, according to MGMA's survey. It is unclear how many spine
surgeons are still performing a procedure the North American Spine Society
placed on its list: using
bone growth material in spinal fusion in the neck. The Food and Drug
Administration issued a safety alert against
this in 2008, noting that the procedure had led to the swelling of neck tissue
that compressed patients' airways, making it hard to breathe or speak.
"I think the use for that purpose has already
fallen off substantially," said Dr. Richard Deyo, a professor at Oregon
Health & Science University and spine researcher. "They've taken on
the easy things."
The only other procedure the society mentioned was
spinal injections, but it was to expand, not restrict their work: They
encouraged doctors to do their injections with the help of imaging, which would
tack on another expense. The group also did not address spinal fusion, which
has more than doubled in frequency between 1998 and 2008, faster than most
procedures, one study showed.
Other research found that
patients with back pain were increasingly likely to get a physician referral,
"presumably for consideration of treatments such as injections and
surgery" while referrals for physical therapy stayed flat over a decade.
Wetzel, the spine society official and an
orthopedic surgeon at Temple University Medical School in Philadelphia, said
that since spinal fusion has been shown to be useful "under very specific
circumstances," the society "didn't feel comfortable making any kind
of blanket statement."
The importance of which items are included is not
just an academic debate, because 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 alerts fire about 100 times a day,"
said Dr. Scott Weingarten, Cedar-Sinai's chief clinical transformation officer.
For example, he said, there has been a decrease in the use of benzodiazepines
and other sedative-hypnotics to treat the elderly, as they result in more
falls, following a recommendation from the American Geriatrics Society for
Choosing Wisely.
"We've got a bunch of other countries knocking
on our door," said Dr. Richard Baron, president of the ABIM Foundation, which solicited the Choosing Wisely lists
from the specialties. "There's a Choosing Wisely Canada. There are health systems
using it, insurers are using it."
Dr. John Santa, medical director for Consumer
Reports, said reducing tests is a worthy goal because test results often prompt
patients to get procedures. He cited electrocardiograms,
which are used to measure the heart’s electrical activity to diagnose heart
disease. "Some people would say, it’s a $50 test, it's
harmless," Santa said. "The false positives you get from EKGs can
cause significant downstream problems. You may think you may have just been
brilliant in detecting some abnormality. That's how stents get put in."
In Annapolis, Md., the Anne Arundel Medical Center
broadcasts "Choosing Wisely" lists on hospital television screens,
places posters on the walls of doctors' offices and discusses the lists in its
magazine that it mails to county residents. The lists are also embedded as
links in electronic patient records so physicians can easily review them.
Dr. Barry Meisenberg, an oncologist in charge of
the hospital's quality efforts, said the lists are helpful when he is trying to
explain to disappointed patients why he is not ordering a particular test.
"It does help that’s not just this guy’s opinion, it actually has the imprimatur
of a society," he said.
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