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“Choosing Wisely” campaign launched

The ABIM Foundation has joined with nine medical specialty societies to develop evidence-based lists of tests and procedures for patients and physicians to discuss and question.  The goal of Choosing Wisely is to help physicians, patients and other stakeholders avoid unnecessary and in some cases harmful interventions and reduce the ever-expanding cost of health care.  Each participating specialty society will identify five tests or procedures whose use should be questioned.  The lists will be announced in April 2012.  The lists are modeled after the National Physicians Alliance project “Five Things You Can Do in Your Practice,” which was funded by the ABIM Foundation.  Consumer Reports will also be participating in the campaign.  One page factsheet here.  Press Release here.  Website here.

Consumer Reports critiques cardiology industrial complex

I’m a longtime subscriber to Consumer Reports magazine. The cover story in CR’s September 2011 issue, entitled “The business of healing hearts: cardiac care is a money-making machine that too often favors profit over science,” attacks marketing campaigns that exploit people’s concerns about heart disease to promote unnecessary and inappropriate tests. The key points:
  1. People often get the wrong tests, wasting resources and often leading to inappropriate treatment.
  2. Angioplasty is overused in nonemergency situations when lifestyle changes and drugs would be just as effective.
  3. Consumers don’t have enough information on quality of care.
  4. The nature of heart disease is often misunderstood to be a kind of plumbing problem. This leads to the idea that the way to prevent future problems is to search for blockages and stent them.  This procedure can be lifesaving in a patient who is in the midst of a heart attack, but has not been shown to be more beneficial in nonemergency situations than a more conservative approach of controlling risk factors with lifestyle changes and drugs.

In addition, CR found in a survey of 8,000 of its subscribers that many people undergo heart-related screening tests such as an electrocardiogram, exercise stress test, or ultrasound of the carotid arteries, “even though such tests aren’t recommended for healthy people.” In addition, many people undergo these screening tests without first investigating the accuracy of the tests or what they would need to do if the test indicated a possible problem.

All of the above is true. However, I found somewhat of a disconnect between the first part of the article, described above, and the second part, where CR attempts to inform its readers on what tests they need and under what circumstances. The problem is that some of the information is not clear enough to provide adequate guidance to the average layperson and at times even seems to conflict with the overall “avoid needless tests” theme.
For example, in two different places they recommend an exercise stress test for “people who are middle-aged or older with multiple heart risk factors who are starting to exercise” (p. 30) and “middle-aged people who are just starting to exercise” (p. 31). First, the second formulation is very broad and would mandate stress tests in many millions of people who are at low risk of coronary heart disease. Even the first formulation is overly broad in my opinion. This is exactly the kind of test — in a person without symptoms — that can lead to the cascade of testing and overtreatment that they were complaining about in the first part of the article. The pretest probability that the person had heart disease would usually be low, meaning that a positive stress test would have a high likelihood of being a false positive. Such a positive test often leads to referral for unnecessary, expensive and invasive procedures. Inevitably some of those people end up in the cath lab and receive stents even though very few of them have the type of disease where revascularization provides a mortality benefit.
They waffle on whether CT angiography should be used. On page 30, they state that “CT angiography might be appropriate for people with inconclusive stress-test results to see whether a somewhat more invasive test, standard angiography, is necessary.” On p. 31, they state that CT angiography is “possibly” appropriate for “people who have chest pain and abnormal results on an EKG and exercise stress test, though most of those people probably need standard angiography instead.” This is farther than I would go and too vague to be useful. I don’t think CT angiography should be used at all given the poor image quality, high rate of false positives, radiation dose, and lack of information on whether a particular stenosis is producing symptoms (see this editorial by Steve Nissen for more background).
They don’t give any advice on whether people with symptoms should get conventional angiography, except to say that angiography without having a stress test first is warranted only in specific situations. Isn’t there some uncertainty over whether angiography is always necessary after a positive stress test? Isn’t simply choosing medical therapy an option? Maybe the evidence isn’t strong one way or the other, but I think they should at least mention that a conservative approach is always an option.
The section under the heading “Get the right treatment” is not exactly wrong, but is too general to provide much guidance for laypersons. “When testing reveals severe blockages, angioplasty or bypass surgery might be warranted.” This is true, but it depends on what you mean by “warranted” and “severe blockages.” First, you always have a choice not to undergo that kind of procedure, even if there is evidence that it might improve outcomes, so “warranted” should not be read to mean “mandatory.” In addition, the average person has no idea what degree of blockage (“stenosis” in doctor-speak) is considered severe, or how the location and number of the stenoses might influence prognosis.
Although in general Consumer Reports is an excellent source of information for consumers, I’m not sure they have figured out the best way to convey health advice in a way that a person faced with making a specific choice about their health can use.   

Addendum August 17, 2011: The Cleveland Clinic had an online health chat on coronary artery disease treatments yesterday, so I took the opportunity to ask Dr. Steven Nissen a question. Here’s my question and his answer:
marilynmann_1 asks: The September 2011 issue of Consumer Reports recommends that a sedentary middle-aged person with cardiac risk factors, who is asymptomatic, get a stress test before starting an exercise program. Do you concur?
Dr__Steven_Nissen: No. It’s sensitivity is about 60% and its specificity is about 60% in patients without symptoms – therefore it is slightly better then a flip of a coin. If the test is positive it may lead to unnecessary further studies that may lead to procedures that are not indicated.