Less is the new more: choosing medical tests and treatments wisely

Picture this scenario: Seven days ago you had a really bad attack of back pain. You can hardly get out of bed, and getting dressed and in and out of the car is slow and painful. It’s making life seem miserable. You’re middle-aged but, other than this pain, are well.

When you visit your GP, after examining you, she says it appears to be “non-specific musculo-skeletal pain”, should settle with time, and that you should stay active.

“Shouldn’t you order me an x-ray to find out what it is?” you ask. “It is really bad!”

Not so long ago, getting an x-ray for acute back pain was the norm. Although it’s now known that they don’t help most cases, they are still used far more frequently than is necessary.

Acute non-specific low back pain is a very common problem that, most of the time, gets better without any treatment. We are not sure anything, except staying active, helps it resolve faster.

X-rays are only helpful to diagnose the rare causes of acute back pain such as cancer (spread from some other origin), infection (very rare nowadays), osteoporotic fractures in elderly folk, or exceptional narrowing of the spinal canal. Most of these have some clinical indications that doctors look out for.

X-rays not only have little to contribute, they have downsides too.

First, they detect problems that may not be relevant (such as disc-space narrowing) and can lead to more investigations, such as computed tomography (CT) scans. Rarely does anything detected from the x-rays or the further investigations contribute to the better management of the condition and resolve a person’s back pain faster.

Second, x-rays themselves are directly harmful: accumulated doses of radiation increase the risk of cancer. While the doses are very small for plain x-rays, they are much higher for CT scans.

Finally, there’s the issue of health costs. Undergoing x-rays for back pain costs a huge amount, both directly and from downstream unnecessary expenses (more investigations to deal with the questionable findings – many of which are called “incidentalomas”), more medical consultations, referrals and so on.

So, not surprisingly, there are moves to try to fix the use of unnecessary tests like this, and a plethora of other tests and treatments.

One move comes from government. Last week federal Health Minister Sussan Ley ordered a review of Medicare item numbers to prune away activities funded from the public purse that are useless.

Another initiative, launching in Australia this week, comes from the clinical professions themselves: the Choosing Wisely campaign. It aims to encourage a conversation between clinicians and patients about tests, treatments and procedures that may provide little or no value, and which may cause harm.

The Choosing Wisely campaign first launched in America in 2012 as collaboration between the American Board of Internal Medicine Foundation, Consumer Reports and nine medical speciality societies. Each society developed a list of five treatments, tests or services that were commonly provided but whose necessity should be questioned and discussed.

The campaign has expanded, with 70 societies now participating. Thirteen countries have adapted and implemented Choosing Wisely.

In Australia, five colleges have participated initially in Choosing Wisely, with the support of NPSMedicineWise:

• the Royal Australian College of General Practitioners (RACGP)
• the Royal College of Pathologists of Australia
• the Australian Society of Clinical Immunology and Allergy (ASCIA)
• the Australasian College for Emergency Medicine (ACEM)
• the Royal Australian and New Zealand College of Radiologists.

Each has identified a list of five “things that clinicians and consumers should question” and a brief rationale. The process typically involved consulting evidence reviews and seeking feedback from college members, overseen by a small working group that each college assembled.

One of the five things on the Royal Australian and New Zealand College of Radiologists’ lists, for example, is:

Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause of low back pain.

The lists contain tests and treatments, as well as some things that should be done and others that should not.

Examples of tests are:

• not automatically doing a CT scan for every head injury unless there are valid clinical indicators for doing it (from ACEM)
• not doing alternative tests for allergies (from ASCIA)
• not regularly monitoring the blood glucose levels of patients with diabetes who do not require insulin (from RACGP).

Examples of “don’t do” treatments are:

• not treating isolated high blood pressure or blood cholesterol levels without first establishing the patient’s absolute risk of a cardiovascular event (from RACGP)
• not using antihistamines for anaphylaxis because this needs another treatment (adrenalin) immediately (from ASCIA).

An example of a “should do” treatment is:

• introducing solid foods, including allergenic foods such as peanuts, to infants from four to six months of age (from ASCIA).

These lists are not just for clinicians. As we recently wrote on The Conversation, our research showed most people overestimate the benefits and underestimate the harms of tests, screens and treatments.

These unrealistic and overly optimistic expectations often result in patients asking clinicians for tests and treatments. Some of these are unnecessary and will provide little, if any, benefit and may cause harm.

Flagging particular tests and treatments for clinicians and patients to discuss carefully prior to use provides the opportunity for accurate and balanced information to be provided and an informed decision made.

It may also counteract the overly optimistic expectations about health interventions that patients have, which are one contributor to continually increasing health-care use and costs.

The Choosing Wisely lists are not about identifying exclusions and services that should never be provided, but rather they are about encouraging conversations. Every patient is different. Decisions about what is best for each person should ideally be made collaboratively between clinicians and patients.

This approach – talking with patients about the problem so they can appreciate the futility of the intervention – is particularly attractive. Compared to a top-down process that might be perceived as rationing and cost-cutting, this approach might achieve better acceptance by the community.

But this requires clinicians to be willing to engage in shared decision-making – a consultation process where a clinician and patient jointly participate in making a decision, having discussed the options and their benefits and harms, and having considered the patient’s values, preferences and circumstances.

Of course, there are many other tests and treatments that did not make it into these initial “top five” lists, but are equally deserving of a quality conversation between clinicians and patients. Hopefully, the launch of Choosing Wisely in Australia will stimulate clinicians and patients to have discussions about all health tests, treatments and screens prior to an informed decision being made.

Yes, the move towards better patient-clinician conversations and shared decision-making will take effort, time, some training and a change in long-established ways of doing things. However, continuing to provide patients with unnecessary treatments and tests without adequate discussion is not an acceptable alternative.

Tammy Hoffmann receives funding from NHMRC and royalties from books about evidence-based practice.

Chris Del Mar receives funding from NHMRC and royalties from books about evidence-based practice.