Norman Swan: hello and welcome to this week’s Health Report with me Norman Swan.
Today: working up a sweat over dementia prevention and saving yourself time and money, the health care budget, as well as reducing potential harm by choosing your tests and treatments wisely with your doctor – from back pain to headaches, to your heart and asthma and beyond.
It’s a project in the United States called Choosing Wisely where specialists have agreed on five things doctors and their patients should question in each of a number of specialties. Dr Christine Cassel is President of the American Board of Internal Medicine and the ABIM Foundation which is behind Choosing Wisely.
Christine Cassel: you know in this country we face an enormous problem with health care costs and we’re not the only ones, but I think we clearly internationally are the outliers in terms of the amount of money we spend per capita and, at the same time, have not been able to find a way to provide universal coverage for all of the citizens. So this challenge has just been becoming greater and greater as the challenge of the global recession has really hit our country, and employers in particular who provide a lot of the health insurance for individuals are looking for ways to how that can be more affordable and the health care reform is looking for ways to have it be more affordable and the patients are looking for ways to have it be more affordable.
So there’s a great environment of discussion about how to control health care costs and an obvious first step for everyone is to reduce waste, unnecessary things that are done and paid for. and we have experts from multiple sources who estimate that up to 30% of what we spend is unnecessary and doesn’t help patients.
Norman Swan: only 30%?
Christine Cassel: (Laughter) only 30%, so that’s a lot when you’re talking about $2 trillion a year. Our foundation works on trying to advance the physician role in improving quality of care and in professionalism and then the patient-centred values of care. We began working with a number of speciality societies, the experts in each of the physician specialties such as cardiology and radiology and oncology to identify lists of five things in each specialty where they feel, the experts feel, that there is significant overuse; and where there should be a dialogue between doctors and patients about whether the patient really needs this. and we began having these discussions. Nine specialty societies wanted to be involved in the first round and then the most powerful part of this is that we partnered with consumer organisations led by Consumer Reports.
Norman Swan: Consumer Reports is almost the American equivalent of the Australian Consumers Association, which is essentially a national consumer body.
Christine Cassel: Yeah, it is the most highly respected voice of consumers, for everything from buying refrigerators to automobiles to any kind of consumer goods. and so they have begun developing greater interest in health care, they put out a whole section on the best buy in drugs for example, evidence-based information about drugs. So their job is to translate these recommendations into information and the evidence behind it that consumers and patients can understand and then disseminate it very broadly on the web and in their magazine, so that when the patient comes to the doctor, the patient is equipped to have the conversation with the doctor and not worried ‘am I not getting something just because my neighbour had this last year, this test, maybe I should be having it’, they’ll be able to actually initiate a discussion with the physician or the physician initiates it, to have a greater understanding about it.
Norman Swan: Before we get into some of the recommendations you’re making, just so that people can get a feel for what you’re talking about here in terms of the tests that you’re recommending not be done in certain circumstances, did you get any legal opinion? Australia is a medically litigation fearful community, it’s even more so in the United States. Physicians might fear by not doing a test and the tiny chance of something bad turning up might expose them to litigation.
Christine Cassel: Well we have a lot of worry about that among physicians in this country and so it’s a big concern. most of the experts who studied this will tell you that it’s not a big part of health care costs in this country but it is a big concern and we need to recognise that.
Norman Swan: It’s reasonably well proven that it’s a driver for over-investigation.
Christine Cassel: There is a lot over-testing, exactly, and so that’s why we would like the patient to understand what’s at stake here and the fact that there are risks involved with many of these investigations. It’s not just a matter, I mean first of all many patients are actually paying out-of-pocket these days for these things in the United States, and so you know they are getting more and more tuned in to what things cost and wanting to know do I really need this. and then also with many of them such as CT scans there is the radiation risk as well and a risk of incidental findings leading to other tests that have risks, so the more we understand that these tests are not without their own risks then I think the better we’ll be in the medical liability environment.
Norman Swan: and what you’re talking about there, just to expand, is that if you do a test where there’s no good reason for it you may find something that was never intended to be found, which might lead to a whole series of other tests, maybe even surgery with side effects which you didn’t need.
Christine Cassel: right, exactly. as you know what we would call an incidental finding, that is just a little spot that actually is not causing any problem but that leads to one test after another, some of which are invasive biopsies, catheterisation etc. which then can have their own complications.
Norman Swan: and apart from getting consumers to ask, do you have a legal opinion that if say the American Academy of Family Physicians makes a recommendation that’s evidence-based, the physician follows that recommendation, when you get into court whether it’s defensible?
Christine Cassel: Well we haven’t tested that, I actually think that having the experts use the evidence in support of this would be greatly helpful in a court case such as that. but you know this campaign has just begun and that’s not really the main purpose of it, so we haven’t had an example like that yet. but I will say that you know where there is good scientific evidence about not doing something physicians are in much better shape when it comes to those kinds of situations.
Norman Swan: So let’s go through some things, particularly those things that I know in Australia are over-used. Five things physicians and patients should question – this one comes from the American Academy of Family Physicians: Don’t do imaging for low back pain within the first six weeks unless red flags are present. I mean we have an epidemic of CT and MRI scans for low back pain in this country as I’m sure you do as well.
Christine Cassel: We do, that’s right and there’s very good evidence, multiple, multiple studies actually extending over a number of years, probably a decade now, that the vast majority – if a person has new onset of lower back pain without any neurological signs, so there’s no sign that there’s really some impingement on a nerve, or on the spinal cord.
Norman Swan: or fever, suggesting infection, or weight loss.
Christine Cassel: exactly, then 99.9% of the time what will fix it is 6 to 8 weeks of physical therapy and if that doesn’t work then you can go to a scan and actually this has been implemented in health care systems in the United States which have ended up saving huge amounts of money and reducing harm from unnecessary surgery. what often happens as you know is that if someone gets an MRI of their spine, particularly if they are over a certain age like 50 or 60 years old, everybody’s spine looks pretty sad -
Norman Swan: It looks horrible.
Christine Cassel: At that age right.
Norman Swan: and in fact the same goes for MRI of the knee, if you do the knee you find a tear of the cartilage which means nothing.
Christine Cassel: So it’s completely unrelated to your back pain but once you look at that and your doctor looks at that and says ‘well, you know we have this operation’ then you may be likely to be impatient and say ‘well let’s just fix it’. and what we know is that back surgery is very serious major surgery with multiple risks of complications and its own recovery period. So people are much wiser just in terms of their own mobility and their own function in trying a few weeks of physical therapy first and the vast majority of people get better with that.
Now if your doctor should of course continue to evaluate you for all these other things, for nerve damage signs, for other systemic signs and if anything comes off that’s suspicious then of course you can alter that plan.
Norman Swan: Don’t routinely prescribe antibiotics for a mild to moderate sinusitis. Again, it would be rare that a patient in Australia comes out of the surgery, seeing the general practitioner, without a prescription for antibiotics.
Christine Cassel: So here what the evidence suggests is that if you don’t have signs of a bacterial infection so here’s it’s a fever and a purulent discharge, or something that has lasted more than a week or two, then the vast majority of those are viral and will not improve with antibiotics. and the unnecessary use of antibiotics is an epidemic which not only can adversely affect the patient who is taking it, because of side effects of drugs, but actually adversely affects all of us because of creating drug-resistant bacteria, which then are much more difficult to deal with when you really do have a bacterial infection.
Norman Swan: and here are some extraordinary numbers and I don’t have the numbers for Australia, I’m not sure we would be able to get them, but sinusitis accounts for 16 million office visits in the United States and $5.8 billion in annual health care costs. that is just extraordinary.
Christine Cassel: and most of that is due to proprietary antibiotic packages people like to get, and they are packaged very nicely and the doctor gives it to you, you take it for five days and you think you’re better. but chances are you’d probably get better anyway.
Norman Swan: and here’s another test overdone in Australia – dual energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. Don’t do it is your recommendation.
Christine Cassel: That’s right, there is no evidence that DEXA scans done before 65 in women or 70 in men will pick up osteoporosis early on in a way that interventions would make a difference. now here again it’s important for your listeners to understand that this is in the absence of any specific risk factors, so this wouldn’t be for a woman who has been taking steroids for example.
Norman Swan: or with a trivial fracture.
Christine Cassel: Yes exactly, who’s had some kind of unusual fracture or unusual bone condition, and this is one of the things I think that has made this campaign so successful in the United States, that it is not one size fits all medicine, in fact it’s quite the opposite. We’re saying every patient needs personalised care and that means don’t just give antibiotics because they have sinusitis, don’t just give an MRI because they have back pain, don’t just give DEXA because the person is a woman, you know that’s cookie cutter medicine it doesn’t really benefit the patient and isn’t personalised to what the patient really needs.
Norman Swan: We could spend all day going through this it’s endlessly fascinating. the one I just want to end on, and we can give people the website and they can go and look for themselves, is: Don’t diagnose or manage asthma without spirometry, and just to explain, spirometry is where it’s not just the little thing that you push out on the little plastic tubular device, this is a proper machine that you breathe out into before and after the blue puffer to see whether or not you truly have asthma, one of the more definitive tests. and you’re saying ‘don’t do it’, you’re saying to GPs, general practitioners, or family physicians ‘don’t say somebody’s got asthma without doing this test’.
Christine Cassel: Well, we’re not saying ‘don’t do the test’, we’re saying ‘do the test’, and the reason for that is because the evidence suggests that a lot of people with breathing difficulties may have other complex illnesses that look like asthma, may cause wheezing and shortness of breath, but that may not actually be asthma, that may be related to heart failure or other kinds of conditions. and therefore you really need to know what the airway reactivity is because you want to make sure that you’re treating the right condition. and here again I hasten to say that each one of these recommendations has come from a group of specialists in the field, either the family physicians and internal medicine primary care physicians, or the people who are specialists in cancer, in radiology, in allergy and immunology, which is where the asthma recommendation came from. So it’s really the people who are up to date with the very latest evidence-based information.
Norman Swan: and how will you know if you have been successful?
Christine Cassel: We have many partners in this and I should tell you that we have 14 additional societies who are now working on their lists of five things for release in the fall (autumn) and a number of the original groups are coming up with more things than the five things, so we expect that this will continue and we believe we’re successful if we can really create, change the culture really of practice where the patient doesn’t think that more is better. Where the patient understands that medicine needs to be personalised and that every test and every treatment comes with its own risk. and that their doctor is a credible source of information for finding out what really works for them.
Norman Swan: and that one option is always doing nothing.
Christine Cassel: one option is doing nothing and especially, and here we emphasise, especially if you have a relationship with the doctor and you can go back to that person. you know these decisions are not one time and that’s all. If there are complications, or it doesn’t seem to be getting better then you can always go back and say ‘let’s re-assess the situation’ and often that’s the smartest thing to do.
Norman Swan: Thank you very much for your time Dr Cassel.
Christine Cassel: Well thank you so much for your interest, I really appreciate it.
Norman Swan: Dr Christine Cassel is President of the American Board of Internal Medicine and the ABIM Foundation. Choosingwisely.org is the website and the list of tests and treatments is impressive, in fact the National Prescribing Service, NPS, here in Australia, also has the brief to encourage the better use of tests and treatments. I should declare a potential conflict in that NPS sponsors my television health show, Tonic on ABC News 24. but anyway, if you’re interested, they’ve just released a pamphlet on the diagnosis and treatment of headaches and that’s at nps.org.au.