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Thursday, February 9, 2012




     An important new article in the Annals of Internal Medicine urges physicians (and ultimately their patients) to limit a lot of common testing based on the value to the patient (Will the test actually improve the patient's outcome?) and the cost to the system, which in the end we all pay.
     They have selected 34 tests as appropriate targets for reduced use. Here I will comment on the tests that I have seen most often used in Plumas County with little or no benefit to either the physician or the patient.
1. Bone Mineral Density Testing: The national guideline from the United States Preventive Services Task Force does not call for routine DEXA scanning of average risk women until age 65. As I have explained in a recent post here, new evidence shows that for average risk women with normal DEXA scans at age 65, they do not need another one for 15 years! I have seen many women who have been coming in for one every year or every other year.
    Even for women at high-risk or who have abnormal scans at baseline, there is little evidence to suggest any benefit to repeating the scans in less than 5 years. 

2. Lipid panel testing. Many people come in for a lipid panel every year or sometimes even more often. The recommendation for asymptomatic health persons is to have this done every 5 years starting at age 30. If you're not on any treatment, there is no need to repeat more often than this. Even if you are on treatment, a British Study (The British Heart Study) has shown that once you select the treatment and just continue the medication, as long as there are no side  effects, you don't need to recheck the lipid panel or adjust the dose (ever). You can still get exactly the same 33% reduction of all-cause mortality and cardiac events that you do when you get all the extra tests and medication adjustments. Why go through all that extra trouble and expense?

3. Pre-operative testing: Many surgeons, almost all, in fact, want patients to get an elaborate set of blood tests, urinalysis, chest x-rays, and ECGs before they have any kind of elective surgery. I recently had occasion to undergo an upper GI endoscopy twice. When I had it done here, the Portola hospital did not require any specific testing, but when I need to have the endoscopy repeated at Saint Mary's they routinely threw in a requirement for blood counts, chemistry panel, coagulation tests, urinalysis, chest x-ray, and ECG. This was more than a little irksome since they did not inform me of this in advance, and because I knew it was ultimately pointless. All tests were in fact normal, and I lost both time and money. This report strongly advises against all forms of routine preoperative testing for average risk adults before any general elective surgery.
      COMMENT: Of course, this is usually not a decision you make yourself. Your surgeon makes it. But you can, and should, ask why. And don't be afraid to bring them a copy of this article and the reference supplied below to encourage them to think twice about ordering unnecessary tests.

4. Colon cancer screening: This group also takes a strong stand against any routine colon cancer screening after the age of 75. You can get it, if you really want it, but there is no evidence of systematic benefit at this age.

5. Cervical cancer screening: There is no reason that a healthy 65 year old woman needs additional Pap smears as long as she has had regular screening up to age 65 (every 3 years) and they have all been negative over the last 10 years.

6. Prostate cancer screening: This group takes only the position that men over age 75 should not be screening for prostate cancer with the PSA test. I encourage the more straight forward recommendation of the United States Preventive Services Task Force--that no man, at any age, should be routinely screened for prostate cancer with a PSA test.

     Here I describe only a handful of the 34 tests covered in the report. But these are the most common ones. If we learn to use these tests correctly, we will solve a lot of the problem. A patient should: "Think not what these tests can do for the physician, but what these tests can really do for you!"

REFERENCE: Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 2012; 156:147-9.

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