Lauran Neergaard, AP
Recent headlines offer a fresh example of how the healthcare system could be subjecting people to too many medical tests — this time research showing millions of older women don't need their bones checked for osteoporosis nearly so often.
Many expers also say cancer screening is overused, from mammograms given too early or too often to prostate cancer tests that may not save lives. Now some of the nuts-and-bolts tests given during checkups or hospital visits are getting a second look, too — things like routine EKGs to check heart health, or chest X-rays before elective surgery. Next under the microscope may be women's yearly pelvic exams. The worry is that if given too often, these tests can waste time and money, and sometimes even do harm if false alarms spur unneeded follow-up care.
So what should be part of a doctor's visit? For patients 65 or older, Medicare offers a list of screenings to print out and discuss during the new annual wellness visit, a benefit that began last year. As of November, more than 1.9 million seniors had taken advantage of the free checkup. For younger adults, figuring out what's necessary and what's overkill is tougher.
"Too often, we order tests without stopping to think about how (if at all) the result will help the patient," wrote Dr. Christine Laine. She's editor of Annals of Internal Medicine, which this month published a list of 37 scenarios where testing is overused. Not even physicians are immune when it comes to their own healthcare. Dr. Steven Weinberger of the American College of Physicians had minor elective surgery for torn knee cartilage about a year ago. The hospital required a pre-operative chest X-ray, an EKG to check his heart, and a full blood work-up — tests he says aren't recommended for an otherwise healthy person at low risk of complications.
Weinberger should know - he led the team that compiled that new list of overused tests. All three examples are on it. "If anyone should have objected, I should have objected, but I took the easy way out. I didn't want to be raising a fuss, quite frankly," he says.
The college of physicians' push for what it calls "high-value, cost-conscious care" — and similar work being published in the Archives of Internal Medicine — aims to get more doctors to think twice so their patients won't be put in that uncomfortable position. Another group, the National Physicians Alliance, is studying whether training primary care doctors in parts of Connecticut, California and Washington about the most overused care will change their habits.
Medical groups have long urged patients not to be shy and to ask why they need a particular test, what its pros and cons are, and what would happen if they skip it. This spring, a campaign called Choosing Wisely promises to provide more specific advice. The group will publish a list of the top five overused tests and treatments from different specialties. Consumer Reports will publish a layman's translation, to help people with these awkward discussions. For now, some recent publications offer this guidance:
- No annual EKGs or other cardiac screening for low-risk patients with no heart disease symptoms. That's been a recommendation of the U.S. Preventive Services Task Force for years. Yet a Consumer Reports survey found 44 percent of people with no symptoms had undergone an EKG or similar screening. Simple blood pressure and cholesterol checks are considered far more valuable.
- Discuss how often you need a bone-density scan for osteoporosis. An initial test is recommended at 65, and Medicare pays for a repeat every two years. A study published last week found that a low-risk woman whose initial scan is healthy can wait up to 15 years for a repeat; those at moderate risk might need re-testing in five years, high-risk women more often.
- Women under 65 need that first bone scan only if they have risk factors such as smoking or prior broken bones, say the two new overtesting lists.
- Most people with low back pain for less than six weeks shouldn't get X-rays or other scans, Weinberger's group stresses.
- Even those all-important cholesterol tests seldom are needed every year, unless yours is high, according to the college of physicians. Otherwise, guidelines generally advise every five years.
- Pap smears for a routine cervical cancer check are only needed once every three years by most women. So why must they return to the doctor every year to get a pelvic exam (minus the Pap)? For no good reason, the Centers for Disease Control and Prevention reported last month. Pelvic exams aren't a good screening tool for ovarian cancer, and shouldn't be required to get birth control pills, the report says.
Yes, simple tests can harm. Cleveland Clinic cardiology chief Dr. Steven Nissen cites a 52-year-old woman who wound up with a heart transplant after another doctor ordered an unneeded cardiac scan that triggered a false alarm and further testing that in turn punctured her aorta. A close relationship with a primary care doctor who knows you well enough to personalize care maximizes your chances of getting only the tests you really need — without wondering if it's all just about saving money, says Dr. Glen Stream of the American Academy of Family Physicians.
"The issue is truly about what is best for patients," he says.