AIM: Imaging dominates list of primary care donts

Diagnostic imaging for low back pain, ECG screening of asymptomatic patients, DEXA screening of younger women and imaging of minor head injuries in children were identified as commonly ordered tests with minimal benefits or risks that outweigh benefits, according to a report published May 23 in Archives of Internal Medicine.

In 2009, the American Board of Internal Medicine Foundation provided the National Physicians Alliance (NPA) a grant to develop and disseminate lists of evidence-based activities that could improve quality and conserve healthcare resources. The project centered on the development of five-item lists geared to primary care providers in family medicine, internal medicine and pediatrics.

NPA recruited 15-member working groups, including the Good Stewardship Working Group, for each of the three specialties and charged the groups with compiling the top five activities “strongly supported by the evidence, and that would lead to significant health benefits, reduce risks and harms to patients and communities and reduce costs,” wrote Stephen R. Smith, MD, of NPA.

The initial activity lists were field tested among 255 physicians, who were surveyed about the potential impact of the activity on the quality and cost of care, the strength of evidence supporting the activity and the ease or difficulty of implementing the activity in their own practice.

There was some similarity between the Top 5 lists in family medicine and internal medicine, noted Smith. Three of the five items on both lists not only overlapped but also related to imaging. “This commonality across specialties reinforced the importance and relevance of addressing overuse of these activities.”

Both specialties identified three imaging-related activities as ‘don’ts.’ According to the lists:

• Don’t do imaging for low back pain within the first six weeks unless red flags are present. Imaging of the lumbar spine before six weeks does not improve outcomes but does increase costs, and low back pain is the fifth most common reason for all physician visits, according to the article.
• Don’t order annual ECGs or other cardiac screening for asymptomatic, low-risk patients. The groups found little evidence that detection of coronary artery stenosis in this population improves outcomes. Plus, false-positive tests can lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms exceed the potential benefits, the groups found.
• Don’t use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors. The study is not cost-effective in younger, low-risk patients, researchers argued.

The Top 5 list in pediatrics contained one imaging activity: "Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.” The groups cited rare detection of traumatic injuries in low-risk patients with few patients requiring surgery. In addition, they noted the risks of radiation-induced cancers among pediatric patients.

NPA plans to distribute the lists to all of its physicians in primary care specialties and form a virtual community to implement the activities.

Smith acknowledged that patient understanding and compliance will be key challenges. “Misunderstanding and miscommunication between physicians and patients explain a significant part of why unnecessary and even harmful tests and treatments are ordered.”

To address this issue, NPA said it will develop patient-focused videos to help patients understand the rationale for the recommendations, including the risk-benefit ratio and the link between overutilization and insurance premiums.