Avitzur, Orly M.D., M.B.A.
Do you really need an X-ray for that low back pain or a computerized tomography (CT) scan to figure out why you're getting headaches? Probably not.
Or let's say you get migraines. When one strikes, should you reach for Fioricet (butalbital, acetaminophen, and caffeine)? Actually, butalbital (and opioids) should probably be the last option.
In fact, many common tests, treatments, and procedures are overprescribed. Sometimes doctors are to blame; other times, patients demand them. All that needless care can risk your health and drain your bank account. It also contributes to rising healthcare costs all around. In 2009, $750 billion dollars were spent on wasted medical services, according to estimates by the Institute of Medicine. The Choosing Wisely program (choosingwisely.org) was created by the American Board of Internal Medicine Foundation (ABIM) to address this waste.
A growing number of national medical organizations—as well as consumer-focused groups such as Consumer Reports—are working with the ABIM Foundation to raise awareness about the overuse of medical resources. The resulting lists of “Five Things Physicians and Patients Should Question” are meant to help patients understand the program's evidence-based recommendations, which are developed from a review of all the existing clinical trial data for a particular test or treatment.
[Disclosure: The author, a practicing neurologist and associate editor for Neurology Today, the American Academy of Neurology's biweekly tabloid newspaper for physicians, also serves as the medical advisor and medical editor to Consumer Reports.]
THREE TESTS TO QUESTION
The first nine medical organizations announced their findings last year, sparking off the discussion with 45 tests and treatments that they believed were often overused. (Go to choosingwisely.org/doctor-patient-lists to read the findings.) The response was so strong that an additional 16 new societies—including the American Academy of Neurology (AAN)—recently contributed their top five selections, for a total of 90 new topics. Several of them address neurologic care and may make a difference in what neurologists like me say to you at your next office visit.
Gary S. Gronseth, M.D., professor and vice-chair of neurology at the University of Kansas, Fellow of the AAN, and Neurology Now Editorial Advisory Board member, was part of the AAN Choosing Wisely team of doctors. The team selected their final top five choices for overused tests and treatments after reviewing a list of 178 submissions from 78 AAN member neurologists. “The Choosing Wisely campaign encourages patients to be active, rather than passive, participants in their care,” says Dr. Gronseth, who advises patients to ask their doctor questions such as “Do I really need that test?”
“Choosing Wisely is all about encouraging dialogue between the patient and his or her physician,” Dr. Gronseth explains.
More neurologic recommendations came out of this second round of Choosing Wisely, with some societies addressing the use of imaging in head injuries and febrile seizures (those brought on by high fever) in children, carotid ultrasound in stroke, positron emission tomography (PET) scans for dementia, and the Lyme disease blood test in patients without exposure or exam findings. So stay tuned: this is a movement with considerable momentum, and one that will change what you hear at the doctor's office.
NEUROLOGY-RELATED RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN'S FIRST ROUND OF FINDINGS:
Don't do imaging for uncomplicated headache.
Although many people who experience severe headaches worry that they are caused by a brain tumor or other serious problem, the American College of Radiology (ACR) says that imaging studies of headache patients without specific risk factors probably won't be useful. (Go to http://bit.ly/RVTUuF to read the statement.)
The ACR also warns that incidental findings (findings discovered unintentionally and unrelated to the condition a person is being treated for) may lead to additional medical procedures that do not improve the patient's well-being. For example, a twist in a blood vessel can be confused for an aneurysm; a prominent area of brain tissue might be misread as a tumor. These incidental findings can cause anxiety, trigger more tests, generate referrals to other specialists, and result in unnecessary treatment. In reality, most people who go to the doctor for headaches have migraines or tension-type headaches. While these can be painful, CTs and MRIs rarely show why they occur or change treatment. (Go to http://bit.ly/xvm4th for the full Neurology Now collection of articles on headache.)
When Does Testing for Headaches Make Sense?
Choosing Wisely recommends that tests be considered if you get an abnormal result from a neurologic examination or your doctor can't confidently diagnose your headache based on your symptoms and examination. And it is suggested that you call your doctor if you have headaches that are:
* Sudden or explosive.
* Different from other headaches you have had in the past, especially if you're 50 or older.
* Brought on by exertion.
* Accompanied by fever, seizure, vomiting, a loss of coordination, or a change in vision, speech, or alertness.
Don't do imaging for low back pain within the first six weeks, unless red flags are present.
Low back pain is the fifth most common reason for all doctor visits, according to the American Academy of Family Physicians. They recommend against doing imaging tests for low back pain within the first six weeks, unless red flags are present. (Go to http://bit.ly/X7D4ht to read the statement.) These red flags include significant or progressive neurologic problems such as weakness or numbness, or the suspicion of serious underlying conditions such as infection in the bone (osteomyelitis).
Evidence reveals that most people with low back pain get better in a month whether they get an X-ray, CT, or MRI scan—or none of the above. In one analysis of six studies looking at a total of 1,800 people with uncomplicated back pain (that is, without red flags), those who had imaging tests fared no better, and at times did worse, than people who took simple steps such as applying heat, taking an over-the-counter pain reliever, and staying active. Another study found that people who had an MRI in the first month after developing pain were eight times more likely to have surgery—and had a five-fold increase in medical expenses—but didn't recover any faster. (See box, “When Does Imaging for Low-Back Pain Make Sense?”)
Moreover, there is risk associated with exposure to X-rays and CT scans: one investigation projected 1,200 new cancers based on the 2.2 million lumbar CTs performed in 2007. Although back X-rays deliver less radiation, they're still 75 times stronger than a chest X-ray.
Don't obtain imaging studies in patients with non-specific low back pain.
The American College of Physicians (ACP) came out with this similar recommendation at the same time, echoing the caution that in patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination, imaging does not improve outcomes. (Go to http://bit.ly/Y7qsor to read it.)
When Does Imaging for Low-Back Pain Make Sense?
Choosing Wisely advises that testing may be called for if:
* You have signs of severe or worsening nerve damage.
* Evidence exists of a serious underlying problem such as cancer or spinal infection.
* There are red flags, such as a history of cancer, unexplained weight loss, fever, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.
RECOMMENDATIONS FROM THE AAN
The American Academy of Neurology released these five recommendations in February (go to http://bit.ly/OiZDJW to read them.):
Don't perform electroencephalography (EEG) for headaches.
The AAN cautions that EEG (recording of the brain's electrical activity) has no advantage over clinical evaluation (relaying your history to your doctor and undergoing a neurologic examination) in diagnosing headache. Performing EEGs in patients with headache increases cost without adding benefit. Whereas a normal EEG in someone who has a headache with complicated features may provide a false sense of security, incidental EEG abnormalities (for example, questionable seizure activity) in a patient with a primary headache disorder may prompt use of additional unnecessary procedures or treatments.
Don't perform imaging of the carotid arteries for simple syncope (fainting) without other neurologic symptoms.
Fainting is a frequent complaint, affecting 40 percent of people during their lifetime. It is commonly caused by conditions that drop blood pressure, such as dehydration. Blockage in the carotid arteries—the two main blood vessels in the neck that supply oxygenated blood to the brain—does not cause fainting; it causes specific neurologic deficits such as weakness on one side.
Studies show that even older people who faint are unlikely to have blockage of these arteries. In addition, carotid imaging may uncover incidental blockages that are wrongly attributed to be the cause of the fainting. This can delay finding the real problem and may subject the patient to additional, risk-associated procedures.
The ACP also addressed fainting in their first top five recommendations, cautioning that imaging studies—CT or MRI—should not be performed for the evaluation of simple fainting spells when a neurologic examination turns out normal.
Don't use opioid or butalbital treatment for migraine except as a last resort.
Migraine is the most frequent cause of headache seen at doctors' offices, urgent care centers, or emergency departments. Although effective migraine-specific treatments have been available for over two decades, many patients continue to receive opioid pain-killers or butalbital for treatment of migraine. Those drugs lack anti-inflammatory effects and do not target the underlying mechanisms of migraine. They should be avoided, says the AAN, not only because better treatments are available, but because these drugs are associated with medication overuse headaches, previously referred to as rebound headaches. Opioids should be reserved for people with medical conditions that forbid migraine-specific treatments or for people who don't respond to these treatments. Even under those circumstances, it advisable that these drugs be used sparingly—nine days a month or less.
Don't prescribe interferon-beta or glatiramer acetate to patients with disability from progressive, non-relapsing forms of multiple sclerosis.
Interferon-beta (Avonex, Betaseron, Extavia, and Rebif) and glatiramer acetate (Copaxone) do not prevent the development of permanent disability in progressive forms of multiple sclerosis (MS), the AAN advises. These medications are costly and have frequent side effects that may adversely affect a patient's quality of life. While the drugs do reduce relapse rates in relapsing-remitting patients without significant disability at the time treatments are initiated, prescribing interferon-beta or glatiramer acetate to patients with disability from progressive forms of MS without recent relapses increases cost of care without adding benefit, and frequently causes troubling side effects. (Go to http://bit.ly/x4E6Fb for more on MS.)
Don't recommend carotid endarterectomy (CEA) for asymptomatic carotid stenosis unless the complication rate is low (less than 3 percent).
CEA is surgery to repair a narrowed carotid artery. When the carotid artery has not caused symptoms—such as a transient ischemic attack (TIA), in which blood flow to the brain stops for a brief period of time—the possibility of stroke can be reduced slightly by CEA. However, the AAN concluded, if the surgery's complication rate is greater than 3 percent, the risk of the surgery actually causing stroke outweighs the chance that it will reduce stroke risk.