Modern medicine effectively incorporates a multitude of tests and procedures to improve the health of patients. However, an estimated $500 billion a year goes toward unnecessary medical practices – tests, procedures, and treatments – that do not benefit patients. “Promoting Good Stewardship in Medicine” is a project of the National Physicians Alliance that identified a number of unnecessary practices found in primary care practices. The following seven practices topped the list:
Imaging studies for low back pain. Low back pain is the fifth most common reason for seeing the doctor, accounting for thousands of visits to primary care physicians each year. In most cases, low back pain is due to injury or overuse of muscles, ligaments, and joints – problems that don’t show up on imaging studies such as x-rays, CT scans, or MRI scans. The vast majority of acute low back pain will resolve on its own within a couple of weeks and performing imaging studies contributes almost nothing to treatment outcome. Exceptions to this are back pain lasting longer than 6 weeks or the presence of “red flags” suggesting a more serious cause. These include neurological deficits, such as urinary incontinence, signs of infection (fever, chills, etc.), a significant injury, or a history of osteoporosis.
Blood chemistry panels in asymptomatic patients. In healthy individuals, performing complete chemistry panels (electrolytes, blood sugar, liver functions, kidney tests, etc.) rarely provides helpful information to assist in patient management. This is true for screening urine tests also. Testing for abnormal lipids (cholesterol, triglycerides, etc.), however, is likely to turn up abnormal results in a significant number of asymptomatic individuals. This provides an opportunity to address an important cause for heart disease and stroke that often remains “silent”. Another blood chemistry test that has been shown to be beneficial is screening for elevated blood sugar, an indication of diabetes, in hypertensive patients.
Electrocardiograms in low risk patients – In asymptomatic individuals or in patients at low risk of having coronary heart disease, there is little evidence that performing electrocardiograms (ECG) improves health outcomes. In fact, on many occasions, the test will be falsely positive which leads to misdiagnosis, unnecessary invasive procedures, and over-treatment.
Using trade name statins for lowering cholesterol – Statins are the most commonly prescribed cholesterol lowering medications. Because of patents held by drug manufacturers, a few years ago, only trade name (Lipitor, Crestor, etc.) were available. Today, there are a number of cheaper generic alternatives. Generics are equally effective in decreasing mortality, heart attacks, and strokes, as long as the medication brings the LDL-cholesterol into the desired range. A switch to a more expensive brand name statin should be considered only if generic statin causes a side effect or does not achieve LDL-cholesterol goals.
DEXA screening for osteoporosis – The dual-energy x-ray absorptiometry (DEXA) scan is the most commonly performed test to assess for osteoporosis. In women under age 65 or in men under 70 with no risk factors, DEXA screening has not been found to improve health outcomes. If certain risk factors are present, such as having a fracture after the age of 50, taking corticosteroids (e.g. prednisone) for a prolonged period, eating a diet deficient in calcium or vitamin D, smoking cigarettes, or drinking alcohol excessively, DEXA screening is more likely to provide information that will have a positive impact on the patient’s health.
Antibiotics for minor sinusitis. Most maxillary sinusitis in the outpatient setting is caused by a viral infection that will resolve on its own. Nevertheless, antibiotics are prescribed in over 80% of doctor visits for acute sinusitis. Antibiotics are required only if symptoms last more than 7 days or if
symptoms worsen after initial improvement.
Pap smears in certain groups of women. There is little argument that regular screening of appropriate women with the Pap test has reduced deaths from cervical cancer. Women younger than age 21 or over the age of 60 who have had a hysterectomy for benign disease, however, do not appear to benefit from this screening. The most commonly detected abnormality in adolescents is cervical dysplasia that typically goes away on its own. Testing in these women usually just leads to anxiety, further unnecessary testing and additional expense. Based on solid evidence, older women who have had a total hysterectomy for a noncancerous problem such as fibroids, no longer need Pap smears.
In most instances, doctors perform these tests, procedures, and treatments with the intention to improve the health of their patients. Unfortunately, statistics do bear out the health benefits of their good intentions. Time will tell, but many other tests or procedures, such as coronary calcium scans, thyroid testing in asymptomatic patients, and vertebroplasty for collapsed vertebrae may also fall into the category of “unnecessary practices”. The problem, however, doesn’t just lie with doctors. Consumers, too, often encourage these needless and expensive practices. Consider the parent who insists that their star athlete receive a MRI for a relatively minor knee injury in order to get “back in the game”. Or patients who insist on receiving antibiotics for a cold because it might turn into something “worse”. We all need to be aware of the problem that unnecessary practices can have not only on our pocketbooks, but also on the quality of medical care.