If anyone knows where health-care dollars are being wasted, it’s primary-care physicians. So, the National Physicians Alliance recently assembled working groups of doctors within three fields of primary care — family medicine, internal medicine and pediatrics — and asked each to come up with five ways to reduce costs in their areas while enhancing patient care.
The groups’ recommendations were then field-tested by 255 other doctors, and the three final “Top 5” lists were published Monday in the Archives of Internal Medicine. The central theme? Less is more. Most of the physicians’ advice focused on eliminating expensive tests and drugs that aren’t shown to improve patient care.
Following is a rundown of their recommendations:
Top 5 List in Family Medicine
1. Don’t do imaging for low back pain within the first six weeks, unless the patient has red flags like progressive neurological deficits. Low back pain is the fifth most common reason for all physician visits, but early imaging only increases costs without improving patient outcomes.
2. Don’t routinely prescribe antibiotics for mild or moderate sinusitis, unless symptoms last more than seven days or worsen after an initial improvement. Despite the fact that most sinusitis is caused by a viral infection, antibiotics are still prescribed in more than 80% of outpatient cases. That adds up: each year sinusitis results in 16 million office visits and $5.8 billion in costs, even though viral infections will clear on their own.
3. Don’t order annual ECGs or other cardiac screening for healthy, low-risk patients with no symptoms. False-positives and other potential harms of the tests, such as unnecessary invasive procedures and overtreatment, are likely to exceed the benefits.
4. Don’t perform Pap tests on patients under 21 or in women who have had hysterectomies for benign disease. In these populations, Pap smears tend to cause unnecessary anxiety and cost, with no improvement in patient outcomes.
5. Don’t do DEXA bone scans to screen for osteoporosis in women under 65 or men under 70 with no risk factors. The scans aren’t cost-effective in younger patients, unless they have risk factors like calcium or vitamin D deficiency, fractures after age 50, long-term corticosteroid use, smoking or alcoholism.
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Top 5 List in Internal Medicine
The recommendations for low back imaging, cardiac screening and DEXA screening are the same as the above. The two additional recommendations are:
1. Don’t do blood chemistry panels or urinalyses for screening in healthy adults with no symptoms. Full blood workups don’t improve health for already healthy adults, except for cholesterol screening and Type 2 diabetes screening in adults with hypertension.
2. Use generic statins when initiating cholesterol-lowering therapy. Generic drugs benefit patients with high cholesterol just as much as popular name brands like Lipitor and Crestor, but cost a great deal less.
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Top 5 List in Pediatrics
1. Don’t prescribe antibiotics for sore throat unless the patient tests positive for streptococcus. Most cases of sore throat are viral, yet antibiotics are prescribed more than half the time, contributing to drug resistance and high costs.
2. Don’t order diagnostic imaging for minor head injuries, unless the child has loss of consciousness or other risk factors like dizziness, neurologic deficits, age under 2, or “raccoon eyes” — blood pooling around the eyes that is often evidence of a basilar skull fracture. Otherwise, imaging low-risk patients rarely detects traumatic abnormalities, while the early exposure to the scans’ radiation can increase kids’ risk of radiation-related cancer.
3. Don’t refer cases of OME (ear infections with fluid) early on. Most cases resolve on their own within three months; however, reasons for early referral include language delay, learning problems or neurologic abnormalities.
4. Advise patients not to use over-the-counter cough and cold medications. More than 10% of children use cough or cold medicine every week, even though there’s little evidence that the drugs reduce cough, runny nose or other cold symptoms. Plus, parents tend to administer improper doses of these medications, which increases the risk of side effects and even death.
5. Use corticosteroid asthma inhalers properly. Inhalers are safe, and when used properly, reduce asthma complications and hospital and emergency room visits.
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Although the guidelines are largely intended for doctors, it helps to have patient understanding and cooperation. “Misunderstanding and miscommunication between physicians and patients explain a significant part of why unnecessary and even harmful tests and treatments are ordered,” wrote the authors. “Patient satisfaction and understanding are closely related and physicians can improve patient satisfaction by focusing on understanding.”