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Neurology Today:
doi: 10.1097/01.NT.0000427566.21364.d4
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CHOOSING WISELY: 5 Things Neurologists and Patients Should Question

Avitzur, Orly MD, MBA

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Choosing Wisely, a campaign developed by the American Board of Internal Medicine Foundation in collaboration with consumer groups including Consumer Reports, hopes to put a dent in the skyrocketing costs of medical expenditures projected to comprise 25 percent of the Gross Domestic Product by 2025.

THE CHOOSING WISELY ...
THE CHOOSING WISELY ...
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In 2009, $750 billion health care spending dollars were expended on wasted medical services, according to estimates by the Institute of Medicine. The Choosing Wisely program was created to address this waste, and a growing number of specialty societies, including the AAN, have signed on to help physicians and patients hold conversations about the best use of health care resources.

The first round of medical organizations announced their findings last year, sparking off the discussion with 45 tests and treatments that they believed were often overused. They've each identified tests or procedures commonly used in their field, whose necessity should be questioned and discussed with their doctors. The resulting lists of “Five Things Physicians and Patients Should Question” is meant to help patients understand evidence-based recommendations to assist them in making wise decisions about the most appropriate care based on their individual situations.

Not surprisingly, quite a few of the first-round selections address neurologic care. [For more on these choices, see “Choosing Wisely: What Other Societies Say About Neurological Care.”]

The response was so strong that this month an additional 16 societies, including the AAN, contributed their top five selections; their findings, totaling 90 new topics, will be discussed at a news briefing in Washington, DC, scheduled for Feb. 21.

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HOW CHOICES WERE MADE

Gary S. Gronseth, MD, professor and vice chair of neurology at the University of Kansas, who is the AAN evidence-based medicine methodologist, was part of the AAN Choosing Wisely neurologist team that included members of the Practice Improvement Subcommittee of the Practice Committee; the committee included experts representing a broad range of specialties. They selected their final top five choices after reviewing a list of 178 submissions from 78 AAN members, and narrowing the options down to a group of the most serious considerations.

“To whittle the choices down, we had panel members rank the candidates based on their potential harms and potential benefits, asking: ‘if the procedure is not performed in this circumstance, will this harm the patient?’” Dr. Gronseth explained. “We also asked members to consider their overall judgment of the benefits derived from eliminating a procedure in the circumstances described; we asked that they include their assessments of the frequency of use of the procedure in the circumstances described, any patient risks or discomfort associated with the procedure, as well as the cost of the procedure or intervention,” he said. “These rankings prompted an informal discussion to select the top ten candidates.”

The remaining ten considerations were then assigned to panel members who performed a pragmatic systemic review of the literature for supporting evidence, especially evidence-based guidelines; based upon the lack of evidence, several choices dropped out.

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FIVE RECOMMENDATIOINS

In February, the group released these five recommendations:

1. Don't perform electroencephalography (EEG) for headaches.

EEG has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes, and increases cost. Recurrent headache is the most common pain problem, affecting 15- to 20-percent of people.

(Source: AAN “Practice Parameter: The electroencephalogram in the evaluation of headache”)

2. Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Occlusive carotid artery disease does not cause fainting, but rather causes focal neurologic deficits such as unilateral weakness. Thus, carotid imaging will not identify the cause of the fainting and increases cost. Fainting is a frequent complaint, affecting 40 percent of people during their lifetime.

(Sources: American Heart Association/American Council of Cardiology Foundation Scientific Statement on the Evaluation of Syncope; The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology; National Institute for Health and Clinical Excellence (NICE) guideline: Transient loss of consciousness (“Blackouts”) Management in Adults and Young People, published in 2010.)

3. Don't use opioid or butalbital treatment for migraine except as a last resort.

Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioids and butalbital can worsen headaches. Opioids should be reserved for those with medical conditions precluding use of migraine-specific treatments or for those who fail these treatments.

(Sources: US Headache Consortium Guidelines, European Federation of Neurological Societies Guidelines on Drug Treatment of Migraine, Institute for Clinical Systems Improvement.)

4. Don't prescribe interferon-beta or glatiramer acetate to patients with disability from progressive, non-relapsing forms of multiple sclerosis (MS).

Interferon-beta and glatiramer acetate do not prevent the development of permanent disability in progressive forms of MS. These medications increase costs and have frequent side effects that may adversely affect quality of life.

(Sources: Cochrane Database of Systematic Reviews.)

5. Don't recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (less than 3 percent).

Surgery to repair a narrowed carotid artery that has not caused symptoms reduces the possibility of stroke slightly; however, this benefit is only seen in situations with a documented combined surgical and angiographic complication rate of less than three percent.

(Sources: Guidelines for Carotid Endarterectomy. A Multidisciplinary Consensus Statement for the Ad Hoc Committee, American Heart Association; Carotid Endarterectomy: an Evidence-Based Report of the Technology and Therapeutics Committee of the American Academy of Neurology.)

“These are only the first five selections,” said Kaiser Permanente research scientist and neurologist, Annette M. Langer-Gould, MD, PhD, member of the Practice Improvement Subcommittee, who chaired the work group. The AAN will be soliciting member input again for the next top five, she added.

In addition to the AAN recommendations, there are other developments in this second round of Choosing Wisely, with societies delving into more neurologic topics such as the use of imaging in head injuries and febrile seizures in children, carotid ultrasound in stroke, PET scans for dementia and the Lyme disease test in patients without exposure or exam findings. Specific hospital treatments are discouraged, as well, including a variety of routine pre-operative tests, the use of urinary catheters, transfusions, and repeat blood testing. And there is a sizeable list of treatments and medications including antibiotics that, under a number of settings, are best avoided.

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CONTROVERSIES AROUND CAMPAIGN

Although Choosing Wisely is clearly an initiative with considerable momentum behind it, it is not one without controversy. Its detractors have raised concerns that it advocates for rationing and that it will make it more difficult for physicians to attain prior authorizations for tests in cases that fall into these categories or contribute to more insurance denials. Most importantly, they say, it does not address tort reform. Indeed, a survey published in the Archives of Internal Medicine in 2011 reported that 42 percent of US primary care physicians believe that patients in their own practice were receiving too much care; only 6 percent said they were receiving too little. Seventy-six percent of those surveyed cited malpractice concerns as the number one factor leading them to practice more aggressively. The way that malpractice concerns lead to more aggressive practice was clear: 83 percent of physicians thought they could easily be sued for failing to order a test that was indicated, but only 21 percent thought they could be sued for ordering a test that was not indicated.

Can the Choosing Wisely selections help defend neurologists who follow those practices? “Guidelines can be introduced in courts as supportive evidence of the soundness of medical decision-making,” said Daniel G. Larriviere, MD, JD, chair of the AAN Ethics, Law and Humanities Committee, and interim chair of the department of neurology at Ochsner Clinic Foundation in New Orleans. He cautioned, however, that “the jury may, at the end, give them relatively little weight if there are other more compelling facts presented.” Dr. Larriviere pointed out that what does protect providers from litigation are tort reform programs which reduce incentives — malpractice caps, and use of medical review boards prior to jury trials, for example.

The program's advocates contend that its goals are not to pigeonhole physicians into a particular way of practice, but rather to educate consumers. “The Choosing Wisely campaign encourages patients to be active, rather than passive, participants in their care,” Dr. Gronseth said. “The initiative is all about encouraging dialogue between the patient and their physician.”

Dr. Larriviere agreed, adding: “It's important to understand that the movement doesn't tell physicians not to order something, but rather, tells patients that they may not need it, so that the autonomy-driven consumer can be persuaded by someone who doesn't have a vested interest in the outcome of that encounter. What's really needed here is not just education but counseling, and the fact that a third party had to intercede may mean that we're not really doing such a great job at it.”

This idea is not new, Dr. Larriviere said; physicians and medical societies have been advising us for quite some time not to order tests without a reasonable foundation. The difference now is that consumers feel more empowered to take control of their health care by making decisions they may or may not understand.

“If we really want to be serious about this, we need to make sure that our role as physicians includes patient education, and counseling about the decisions they need to make,” he said.

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CHOOSING WISELY: WHAT OTHER SOCIETIES SAY ABOUT NEUROLOGICAL CARE

As part of the Choosing Wisely initiative, other medical organizations and societies have addressed areas that relate to neurologic care. This is what they've had to say thus far:

* Don't do imaging for uncomplicated headache.

The American College of Radiology says that performing imaging studies in headache patients who do not have specific risk factors is unlikely to change management or improve outcome. It also warns that incidental findings often lead to additional medical procedures and expenses that do not improve patient well-being.

* Don't do imaging for low back pain within the first six weeks, unless red flags are present.

The American Academy of Family Physicians points out that because imaging tests don't improve outcomes in back pain and do increase costs, it's unnecessary to order them within the first six weeks, unless there are red flags. These include the presence of significant or progressive neurological deficits or the suspicion of serious underlying conditions such as osteomyelitis.

* 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 an appropriate history and physical examination, imaging studies do not improve outcomes.

* In the evaluation of simple syncope and a normal neurological examination, don't obtain brain imaging studies (CT or MRI).

The ACP also recommended that with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies.

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FOR FURTHER READING:

• Choosing Wisely initiative: http://choosingwisely.org.

• Non-AAN medical society picks for Choosing Wisely: http://bit.ly/yGDxiQ.

• Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians' views on US health care: a brief report. Arch Intern Med 2011;171(17):1582–1585.

• AAN Practice Parameter: The electroencephalogram in the evaluation of headache: http://bit.ly/WTpwSw.

• AHA/ACCF scientific statement on the evaluation of syncope: http://bit.ly/11ONTZ6.

• The task force for the diagnosis and management of syncope of the European Society of Cardiology: http://bit.ly/VXR11C.

• National Institute for Health and Clinical Excellence (NICE) guideline: Transient loss of consciousness (“Blackouts”) management in adults and young people: http://bit.ly/Ui1lQW.

• US Headache Consortium guidelines: http://bit.ly/WTzRhk.

• European Federation of Neurological Societies guidelines on drug treatment of migraine: http://bit.ly/8iivXB.

• Guidelines for carotid endarterectomy. A multidisciplinary consensus statement for the ad hoc committee, American Heart Association: http://bit.ly/WdM0l0.

• Carotid endarterectomy: An evidence-based report of the Technology and Therapeutics Committee of the American Academy of Neurology: http://bit.ly/VifWyg.

©2013 American Academy of Neurology

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