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Neurology Today:
doi: 10.1097/01.NT.0000418589.06631.26
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What Diagnostic Tests Are Unnecessary? Neurology Weighs in on ‘Choosing Wisely’

Butcher, Lola

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When the AAN issued its call for suggestions of neurology-related tests, procedures, and treatments that are frequently performed even though they are unnecessary, 80 neurologists submitted nearly 200 ideas.

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As a participant in the new Choosing Wisely campaign, the AAN will use those suggestions to create a “Top Five” list of tests and procedures for neurologic disorders that physicians and patients should question. The campaign, launched earlier this year by the American Board of Internal Medicine (ABIM) Foundation, responds to the growing awareness that many common — but unnecessary — health care practices add to the nation's health care costs and may even be dangerous to patients. For example, patients with simple faints often are referred for a carotid imaging study, said Gary S. Gronseth, MD, AAN's evidence-based medicine methodologist.

“From a theoretical basis, carotid artery disease shouldn't cause simple faints,” said Dr. Gronseth, vice chairman of the neurology department at the University of Kansas Medical Center, whose research focuses on evidence-based medicine. “But it's commonly done, and if any symptomatic stenosis is found, patients are sent for surgery, and that may be inappropriate.”

Another potentially dangerous — but common — situation is the overuse of CT imaging on headache patients.

“I've known patients who get five to 10 CT scans a year,” he said. “That's a major problem. There's a cumulative radiation risk of exposure, and the test isn't necessary.”

Rod Larson, AAN's chief health policy officer, said Choosing Wisely is a new way for the Academy to support its commitment to high-quality evidence-based care.

“The campaign is really geared toward generating better dialogue between patients and physicians and is intended to be a tool to be in addition to the clinical judgment of physicians,” he said.

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WHAT IS CHOOSING WISELY?

The ABIM Foundation's goal for Choosing Wisely is to help physicians and patients choose health care that meets four standards: it is supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary.

The campaign kicked off in April when the American College of Physicians, the American Society of Nephrology, the American Society of Clinical Oncology and six other medical organizations each published “Top Five” lists of tests and procedures that are frequently performed although scientific evidence does not support them.

For example, the American College of Cardiology (ACC) topped its list with this: Don't perform stress cardiac imaging or advanced imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. The ACC said up to 45 percent of unnecessary cardiac screening is performed on low-risk patients.

The ABIM Foundation has partnered with Consumer Reports, which is working to educate patients about the “Top Five” lists and help them use that information to engage their physicians in discussions about tests and treatments.

The Academy is one of 14 medical societies that will reveal its “Top Five” lists when the second phase of the campaign launches later this year. ABIM Foundation expects many other medical groups to join the campaign in 2013 and beyond.

“If we're ever going to bend the cost curve and improve quality in American health care, we have to do efforts like this,” said Gary M. Franklin, MD, MPH, a neurologist who serves as medical director for the Washington State Department of Labor and Industries. “To the extent that they are voluntary efforts by professional groups, all the better. That's what we should be doing, and I'm really proud that the American Academy of Neurology is participating in this.”

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WHAT IS UNNECESSARY?

The use of unnecessary medical tests and procedures reflects several problems in America's health care system. For one thing, physicians typically are not trained to think about the cost-effectiveness of the diagnostic and treatment decisions they make, said S. Claiborne Johnston, MD, PhD, a neurologist who directs the Clinical and Translational Science Institute at the University of California, San Francisco.

“Some of the things we do simply don't add value, and they definitely add cost,” he said. “We are trained to be entirely focused on doing the absolute best thing for the patient in front of us. And if you take that to the extreme, why shouldn't we get weekly head MRI's on everyone, because you may find a tumor, right?”

Another factor: Patients ask for scans they do not really need.

“Patients are hearing all kinds of stuff from their friends and relatives or they're going online and looking stuff up, and then they worry,” he said. “The vast majority of symptoms don't represent a serious disease, but it is just easier to get a CT scan or an MRI than it is to see the patient two or three more times to make sure they are OK.”

Health care's perverse financial incentives — physicians are paid poorly to spend face-to-face time with their patients, but those who own imaging equipment are highly paid for scans — encourage physicians to overuse technology.

Additionally, many physicians order tests because they are worried about malpractice lawsuits. “It's hard to quantify how often you might get a test because you're afraid you might get sued if you don't,” Dr. Johnston said. “We are punished for not getting enough tests but never punished for getting too many.”

Dr. Johnston's own “most often unwarranted” list would include duplicative tests.

“Say, a patient comes in with a stroke and they get both a head CT and an MRI scan when, in reality, we don't need both studies except for a small subset of patients,” he said.

Dr. Franklin agrees that inappropriate imaging may be a priority for the Academy's “Top Five” list. For example, although patients suffering lower back pain often get better with physical therapy or even no intervention, both patients and physicians are too quick to want scans — that may lead to unwarranted treatment.

“You do find stuff when you image someone's back,” Dr. Franklin said. “That actually pushes us to do things that we should not be doing, like surgery that is not really indicated. That has downstream cost implications and health implications for patients.”

His list of things physicians and patients should question might include nerve conduction studies and electroencephalography (EEG).

“Especially EEG's for chronic headaches and other issues that either don't require an EEG at all, but certainly don't require repetitive EEG's,” he said. “I'd say self-referral for advanced imaging is a problem. The CT scanners are a problem because of radiation issues, and the MRI's are a problem in regard to overuse and cost.”

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CREATING THE LIST

The suggestions submitted by Academy members were screened by a nine-member work group, which was assigned to identify about 11 of the best submissions.

“The first step is an anonymous vote, where we rank the importance of these nominations in terms of minimizing discomfort and potential harms associated with these tests and procedures,” Dr. Gronseth said.

Each of those top contenders will be assigned to a member of the work group who will conduct a literature search for supporting evidence and write a rationale for the item. Then work group members will re-convene to review the rationales and vet each item on several domains, such as frequency of use, discomfort to the patient, cost and other factors, he said.

The work group's recommendations for the “Top Five” list will be submitted to various AAN committees, patient organizations and other stakeholders, Larson said, and eventually to the AAN Practice Committee and Board of Directors for final approval.

In early September, the Academy will submit its list to the ABIM Foundation, which will publish it later this year.

©2012 American Academy of Neurology

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