But now it's time to take a long hard look in the mirror.
Medical specialty organizations are being asked to come up with a list of 5 tests or treatments that are over-utilized or may actually be harmful. This effort, called the Choosing Wisely Initiative, is being spearheaded by the American Board of Internal Medicine (ABIM) Foundation. ABIM President and renowned geriatrician Christine Cassel was quoted in today's New York Times saying:
“In fact, rationing is not necessary if you just don’t do the things that don’t help.”This same article notes that as much as 1/3 of health care costs are wasted on unnecessary hospitalizations, tests, and treatments.
So far 9 specialty boards have come up with their lists - the boards and there list are here - but Geriatrics and Palliative Medicine are not one of the 9. Are we really "holier than thou?" I don't think so.
I suspect we can come up with 5 tests or treatments for each specialty. It might be more fun to come up with lists for the cardiologists, oncologists, or surgeons, but that's not the point. Ask not what another specialty should not be doing, but what you can do less of yourself.
It's easier to come up with ideas if you don't think of them as a hard and fast rules (never do x), but as a list of things doctors and patients should question routinely doing in geriatrics or palliative care.
So to jump start things, here are two from each field:
Geriatrics
1. Screening for cancer in patients who are unlikely to benefit.
2. Insulin sliding scales
Palliative Care
1. Using more expensive analgesics without evidence of superiority to less expensive alternatives
2. Using oxygen instead of forced air
Let's figure this out together. Or someone from another specialty may come up with our list for us!
by: Alex Smith
11 comments:
1. Prescribe docusate.
2. Prescribe more expensive benzodiazepine, e.g. midazolam when a less expensive one is available, e.g. lorazepam.
for starters ...
Paul McIntyre
Halifax, Canada
Thanks Alex for getting this conversation started. AGS will be working on our list over the summer and will be in the second wave of organizations (announcement slated for early fall). I believe AAHPM is on the same timeframe. We welcome everyone's thinking on this topic.
Thank you for calling attention to this initiative. AAHPM is now an official partner of the Choosing Wisely campaign and will be participating in the next round of recommendations (to be released in the fall). Keep an eye on www.aahpm.org for details about how to contribute to the Academy’s process of determining 5 tests and interventions that warrant closer examination by patients and physicians.
colace and miralax for opioid related constipation
ongoing use of cholesterol medications when life expectany = months
My number 1:
Videofluoroscopic Swallowing Study to assess swallow function and need for PEG tube placement in individuals with advanced dementia.
Geriatrics:
Don't administer a Folstein MMSE (saving a buck a test there). :)
Don't initiate hemodialysis in an elderly patient without a thorough discussion of risks and benefits (especially the discussion of likely functional decline).
Institute a nationwide POLST paradigm, and give people who complete one a coupon to Denny's.
Stop the indiscriminate prescription of iron and PPIs associated with hospital admissions (or at minimum review the continued need for them).
Don't do PAP smears on elderly women who have had three consecutive normals.
Don't do colorectal or breast cancer screening on patients with less than 10 year life expectancies (or at least not in those with less than 5 year LEs).
Don't do screening PSAs at all.
I think I've seen some geriatricians oversell cholinesterase inhibitors. (I know there is data, but "overuse" can also come from overselling benefits and underselling risks)
1. Ordering albumin/prealbumin to check for malnutrition
2. Ordering 'therapeutic' diets for folks with very limited life expectancy or advanced dementia.
3. along the lines of insulin sliding scale, let's stop doing fingerstick glucose checks for folks who won't benefit from tight control, especially on those with limited life expectancy
Use of Aricept and other drugs in this class in patients who are bed bound with advanced dementia. Ditto Namenda. Continuing cholesterol lowering medications and Plavix in patients with a 6 month life expectancy. Swallow evals-this has become a whole industry-total waste of time. Low specificity and sensitivity and patients refuse to take the thickened liquids and then get dehydrated. Screening for things not likely to result in improved quality of lie.
Ordering plain CT scans of the head for elderly patient with a documented history of dementia who are delirious if they are awake without focal findings
1. Stop Fosamax/antibone resorptive medications for patients with dementia or bed bound patients.
2. Review reasons for PPI use or continued usage
3. Lipid, EKG, HbA1c mandatory testing by pharmacists for patients on Antipsychotics in severely demented patients or those on hospice care.
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