December 10, 2013

New Winthrop health program urges patients, physicians to question tests

Patients should ask doctors if a test is really needed, what the risks are, whether there are simpler or safer options, what would happen without the service and how much it will cost.

By Susan McMillan smcmillan@centralmaine.com
Staff Writer

WINTHROP — An MRI for low back pain could lead to diagnosis and vital treatment for a serious underlying problem.

click image to enlarge

MEDICAL CHOICES: Crystal Beaulieu, left, talks with Dr. Michelle Mosher during an office visit on Friday at Winthrop Family Medicine in Winthrop, which recently received a grant that encourages physicians to talk to patients about conducting tests only when they add value to a diagnosis.

Staff photo by Joe Phelan

 

Winthrop Family Medicine is a pilot site for Choosing Wisely, an initiative that urges patients and health care providers to think twice before ordering tests or procedures that don’t necessarily improve outcomes. Participants will consider recommendations like these from the American Academy of Family Physicians:

• Don’t do imaging for lower back pain within the first six weeks, unless there are red flags.

• Don’t schedule elective Cesarean deliveries before 39 weeks of gestation.

• Don’t screen adolescents for scoliosis.

• Don’t require a physical exam to prescribe oral contraceptives.

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Winthrop Family Medicine is a pilot site for Choosing Wisely, an initiative that urges patients and health care providers to think twice before ordering tests or procedures that don’t necessarily improve outcomes. Participants will consider recommendations like these from the American Academy of Family Physicians:

• Don’t do imaging for lower back pain within the first six weeks, unless there are red flags.

• Don’t schedule elective Cesarean deliveries before 39 weeks of gestation.

• Don’t screen adolescents for scoliosis.

• Don’t require a physical exam to prescribe oral contraceptives.

It could also lead to surgery, big medical bills and time off work for patients who would have felt just as well in the long run if they’d taken a pain reliever and used a heating pad.

Lack of evidence for the value of imaging in most cases of low back pain put it first on a list of tests and treatments that physicians and patients should question — a list that will play a key role in conversations at Winthrop Family Medicine in 2014 and beyond.

The practice, which is part of MaineGeneral Health, has been chosen as a pilot site for Choosing Wisely, a national initiative to reduce overtreatment.

Winthrop Family Medicine’s staff and patients will be encouraged to think twice about ordering tests and procedures that research suggests are unlikely to improve a patient’s health and may even worsen it.

“Our world has gone a little rampant in more-is-better, and that’s not really the case in many instances,” said Kellie Slate Vitcavage, the Choosing Wisely project director at Maine Quality Counts, an independent health care collaborative based in the Augusta area.

Unnecessary procedures are a significant source of waste in the American health care system. A 2012 article in the Journal of the American Medical Association said overtreatment cost Medicare and Medicaid as much as $87 billion in 2011, and the Institute of Medicine estimated the cost of unnecessary services at $210 billion in 2009.

Although excess costs are a problem, John Barnes, medical director at Winthrop Family Medicine, said the central question of discussions between providers and patients will be which procedures provide the most benefit.

“If I just focused on costs, I’d just say, ‘Let’s do less tests on you,’” Barnes said. “If I focused on value, I’d say, ‘Let’s cut out all the tests that don’t add value to your care, and see where that leaves us.’”

Barnes said patients may ask for procedures that won’t necessarily help them because anecdotes about a test that saved someone’s life are powerful, and more of those stories than ever are available on the Internet. In addition, health insurance shields most consumers from knowing the true cost of health care services.

There are other structural incentives for overtreatment, including the fee-for-service model that pays providers for quantity rather than the quality of care, and ordering of unnecessary tests to guard against liability for malpractice.

Choosing Wisely is an effort of the American Board of Internal Medicine Foundation and is partnered with Consumer Reports to communicate to patients some evidence-based recommendations that in some cases were already widely known among physicians.

Forty-six medical specialty societies, from radiology to reproductive medicine, have published lists of “five things physicians and patients should question.”

Because it’s a general medical practice, Winthrop Family Medicine will focus on the 15 recommendations from the American Academy of Family Physicians.

Barnes said the practice chose a team approach to the initiative so that patients and all staff will have the same foundation for discussion and decisions.

When talking with a patient about sinusitis, for example, a medical assistant will provide a one-page sheet written in plain language about when antibiotics do and don’t help, Barnes said. Posters will be hung on the walls in the waiting room and staff break room, and providers will talk about different recommendation lists at monthly meetings.

After a few months, the practice will start surveying patients about whether they’ve noticed anything and if so, whether the “things to question” impacted their decisions.

(Continued on page 2)

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