Sunday, March 3, 2013

Choosing Wisely's curious omissions

Last month, the American Board of Internal Medicine Foundation's Choosing Wisely Initiative announced the release of a second round of lists of 5 things that physicians and patients should question, based on evidence that certain tests or procedures are not beneficial in specific clinical situations. American Family Physician will soon be updating its list of primary care-relevant items from the Choosing Wisely campaign, and its Facebook and Twitter accounts will highlight old and new entries daily over the next few months. This AAFP News Now article provides more information about the American Academy of Family Physicians' most recent items, which include elective labor inductions and unnecessary cervical cancer screenings.

Notably absent from the lists of the primary care specialty societies and the American Urological Association is routine prostate-specific antigen (PSA) testing, which both the Cochrane Collaboration and the U.S. Preventive Services Task Force have concluded does not improve men's health outcomes. Even though the American Cancer Society and the AUA still support selective use of the PSA test in older men who have been adequately informed of its potential harms, no medical group supports the still-common practice of ordering PSA screening without first discussing it with the patient.

Another curious omission from the top 5 lists of cardiology and thoracic surgery organizations is angioplasty or coronary artery bypass surgery for stable coronary artery disease, which are frequently performed in the U.S. but have no clinical advantages over initial medical management.

From a population health perspective, curtailing prostate cancer overdiagnosis and unnecessary cardiac interventions would be worthy goals to add to a "don't do" list that collectively includes more than one hundred items. Instead, these omissions say quite a bit about the persistence of perverse financial and medicolegal incentives in primary and subspecialty medicine. After all, no one ever sued a doctor for diagnosing cancer (even if it didn't need to be diagnosed) or placing a stent in a partially occluded coronary artery (even if it didn't need to be placed), and insurers rarely (if ever) decline to pay for these wasteful tests and procedures.


A shortened version of the above post first appeared on the AFP Community Blog.