Medical Societies Release Lists of Overused Tests and Procedures

The American College of Cardiology (ACC) and other medical societies have released lists of commonly overused or misused tests of procedures. The action is part of Choosing Wisely, a broad initiative from the ABIM foundation.

Here are the five tests or procedures identified by the ACC:

1. Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given if there are no symptoms of heart disease or high-risk factors like diabetes or peripheral arterial disease (PAD) are not present.
2. Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given as part of a routine annual follow up in patients who have had no change in signs or symptoms.
3. Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given prior to performing low-risk surgery that is not related to heart disease.
4. Echocardiography, which uses sound waves to create images of the heart, should not be used as routine follow-up care in adults with mild heart valve disease who have had no change in signs or symptoms
5. Patients experiencing a heart attack and undergoing a procedure called percutaneous coronary intervention (PCI) should not have stents placed in an artery or arteries beyond those responsible for the heart attack.

Here is the list from the American Society of Nuclear Cardiology:

1. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
2. Don’t perform cardiac imaging for patients who are at low risk.
3. Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
4. Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
5. Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

Here are some other cardiovascular-related items from other medical societies:

• American College of Physicians: Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary 1 heart disease.
• American College of Physicians: In patients with low pretest probability of venous thromboembo- lism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
• American College of Radiology: Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
• American Academy of Family Physicians: Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

Here is the press release from the ACC:

THE AMERICAN COLLEGE OF CARDIOLOGY RELEASES LIST OF COMMONLY USED – BUT NOT ALWAYS NECESSARY – TESTS OR PROCEDURES

Group Aims to Encourage Physician and Patient Conversations by

Identifying Five Tests or Procedures That May Be

Overused or Misused in Cardiology 

WASHINGTON, DC – The American College of Cardiology today released a list of “Five Things Physicians and Patients Should Question” in cardiology as part of Choosing Wisely, an initiative of the ABIM Foundation.  The list identifies five targeted, evidence-based recommendations that can support physicians in working with their patients to make wise choices about their care.

The American College of Cardiology’s list identified the following five recommendations:

1.      Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given if there are no symptoms of heart disease or high-risk factors like diabetes or peripheral arterial disease (PAD) are not present.

2.      Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given as part of a routine annual follow up in patients who have had no change in signs or symptoms.

3.      Cardiac imaging tests (particularly, stress tests or advanced non-invasive imaging) should not be given prior to performing low-risk surgery that is not related to heart disease.

4.      Echocardiography, which uses sound waves to create images of the heart, should not be used as routine follow-up care in adults with mild heart valve disease who have had no change in signs or symptoms

5.      Patients experiencing a heart attack and undergoing a procedure called percutaneous coronary intervention (PCI) should not have stents placed in an artery or arteries beyond those responsible for the heart attack.

“We believe that providing quality care guided by the latest research and guidelines is the best way to manage healthcare resources,” said James W. Fasules, MD, FACC, Senior Vice President of Advocacy at the American College of Cardiology. “Informed conversations between physicians and patients are a critical element of quality care. We were pleased to join the Choosing Wisely initiative to raise awareness in the medical community and among patients. More care is not always better care. We support the right care at the right time.”

All the lists released today as part of Choosing Wisely were developed by the partner organizations after careful consideration and review over many months. Using the most current evidence about management and treatment options within their specialty areas of expertise, the “Five Things” lists include recommendations that can make the biggest impact on patient care, safety and quality.

The American College of Cardiology (ACC) asked its standing clinical councils to recommend between three and five procedures that should not be performed or should be performed more rarely and only in specific circumstances. ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the tightest inappropriate score in the AUCs and were Class III recommendations in the guidelines. The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval. ACC’s disclosure and conflict of interest policy can be found athttp://www.cardiosource.org/RWI.

Also working with the ABIM Foundation to lead the campaign is Consumer Reports, the nation’s leading expert, independent, nonprofit consumer organization.

Several organizations have joined Consumer Reports to distribute patient-friendly resources for consumers and physicians to engage in these important conversations:

• AARP
• Alliance Health
• Midwest Business Group on Health
• National Business Coalition on Health
• National Business Group on Health
• National Center for Farmworker Health
• National Partnership for Women and Families
• Pacific Business Group on Health
• Leapfrog Group
• SEIU
• The Wikipedia Community (through a dedicated Wikipedian-in-Residence)

Eight other national medical specialty societies released individual lists of recommendations today, covering tests or procedures within their areas of expertise that are commonly used but not always necessary. By creating and releasing the lists, the groups aim to spark nationwide conversations between physicians and patients about the need – or lack thereof – for many frequently ordered tests or treatments

Experts agree that the current way health care is delivered in America contains too much waste—some say that as much as 30 percent of care delivered in the United States is duplicative or unnecessary and may not improve people’s health.

The Choosing Wisely campaign seeks to help physicians, patients and other health care stakeholders think and talk about overuse or misuse of health care resources. It is part of the ABIM Foundation’s goal of promoting wise choices by clinicians and patients in order to improve health care outcomes, provide patient-centered care that avoids unnecessary and even harmful interventions, and reduce the rapidly-expanding costs of the health care system.

Releasing lists along with the American College of Cardiology today are:

• American Academy of Allergy, Asthma & Immunology
• American Academy of Family Physicians
• American College of Physicians
• American College of Radiology
• American Gastroenterological Association
• American Society of Clinical Oncology
• American Society of Nephrology
• American Society of Nuclear Cardiology

New societies joining the campaign and releasing lists in fall 2012 include:

• American Academy of Hospice and Palliative Medicine
• American Academy of Otolaryngology–Head and Neck Surgery
• American College of Rheumatology
• American Geriatrics Society
• American Society for Clinical Pathology
• American Society of Echocardiography
• Society of Hospital Medicine
• Society of Nuclear Medicine

To learn more about Choosing Wisely, visit www.ChoosingWisely.org.

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