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Doctors' panels in the US are strongly recommending fewer tests for patients to limit unnecessary care and over-hospitalisation.

In a move likely to alter treatment standards in hospitals and doctors' offices nationwide, a group of nine medical specialty boards plans to recommend that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes onethird of medical spending in the United States.

Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.

Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.
The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.

TREADMILL TEST


Every year, hundreds of thousands of older Americans get on a treadmill in a doctor's office and walk or jog as an electrocardiogram monitors their heart function. But a growing number of medical authorities would like to make routine screening using the procedure, known as the treadmill or exercise stress test, largely a thing of the past. An expert government panel, the United States Preventive Services Task Force, joined the call by recommending against routine testing with electrocardiograms, or EKGs, in people who have no known risk factors or symptoms of heart disease, like shortness of breath or chest pains.

For people at higher risk of heart disease, the panel found there was "insufficient evidence" to determine the benefits and harms of screening with the EKG test - either at rest or during exercise - and advised that it be considered case by case basis. In those instances, said Dr Michael L LeFevre, a vice chairman of the task force and a professor of family and community medicine at the University of Missouri, patients should discuss with their doctors their medical histories and circumstances - including age, blood pressure and cholesterol levels, and lifestyle - to determine whether an EKG test might make sense.

The usefulness of the stress test has been questioned for some time. The problems associated with the test can outweigh its benefit in many people, perhaps even leading to unnecessary harm.

Treadmill stress tests are relatively quick and cheap compared with more invasive tests, and some doctors believe they can identify people with narrowed arteries that put them at risk of having a first heart attack. But studies have shown that the cause of such heart attacks is usually the sudden rupturing of plaque, something the test is unable to predict. And when used on people who are at low risk for heart disease, false positive results can lead to unnecessary anxiety and more costly procedures, like a coronary angiogram.

MRIS


The list of tests and procedures they advise against includes MRIs, ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis - all quite common. The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches.

MEDICATION


The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

SCANS FOR BREAST AND PROSTATE CANCERS


Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the US Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

"Any information that can help inform medical decisions is good - the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make, " said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. "With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients' ability to make decisions themselves. "

Dr Christine K Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans' health care needs as long as care is appropriate. "In fact, rationing is not necessary if you just don't do the things that don't help. "

Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalisations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.

CT SCANS


Some of the tests being discouraged - like CT scans for someone who fainted but has no other neurological problems - are largely motivated by concerns over malpractice lawsuits, experts said. Clear, evidencebased guidelines will go far both to reassure physicians and to shield them from litigation.

Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.

"These all sound reasonable, but don't forget that every person you're looking after is unique, " said Dr Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group's advice would make tailoring care to individual patients harder. "This kind of one-size-fits-all approach can be a real detriment to good care. "

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