TORONTO — The American College of Physicians will soon begin issuing recommendations aimed at eliminating overused and misused diagnostic studies and treatments that do nothing to improve patient care.
The High-Value, Cost-Conscious Care Initiative, which was launched at the ACP's annual meeting in April, will compare treatments and diagnostics for a number of diseases and assess their benefits, harms, and costs. The ACP's Clinical Efficacy Assessment Technical Advisory Committee will make the recommendations and submit them to the Annals of Internal Medicine for publication.
They plan to start with the “low-hanging fruit” in health care where there is already sufficient evidence to make recommendations, ACP leaders said at the annual meeting. These recommendations, which will be issued in the next few months, could include evaluations of the appropriateness of certain preoperative screening tests, for example. Additional recommendations will follow over the next several months.
“We feel that physicians really need to understand the value of different diagnostic and treatment strategies relative to each other and relative to the costs that are incurred,” said Dr. Steven E. Weinberger, senior vice president for medical education and publishing at the ACP. “At the same time, patients must have sufficient information to make informed choices in conjunction with their physician's advice.”
Cost will be a factor in the ACP's assessment of treatments and diagnostics, but this is not rationing, Dr. Weinberger said. Instead, he called it a “rational” approach. For example, if treatment A is more effective than treatment B, but costs more, the ACP would not recommend limiting access to treatment A, he said.
But the ACP is staying away from thornier situations such as when treatment A is more effective and more costly, but treatment B is less expensive and also a good option for patients. Instead, Dr. Weinberger said the ACP plans to focus specifically on issues of overuse and misuse of ineffective treatments. That approach could yield real savings for the health care system. The Congressional Budget Office estimates that the United States spends as much as $700 billion per year on tests and procedures that do not improve health outcomes.
There are several factors that drive overuse and inappropriate use of treatments and diagnostics, Dr. Weinberger said, including the reflexive practice of medicine, defensive medicine, and patient expectations.
Another part of the problem is that the U.S. health care system has financial and cultural incentives to do more, not less, said Dr. Paul G. Shekelle, chair of the ACP's Clinical Efficacy Assessment Technical Advisory Committee. “All the things in America point toward doing more, and yet as we've found, sometimes doing more isn't necessarily always doing better,” he said.
One potential benefit of the initiative is that it could help to better educate patients, according to Dr. Joseph Stubbs, president of the ACP. Dr. Stubbs, who practices internal medicine in Albany, Ga., said he often sees patients spending a lot of time and money on over-the-counter and supplement products whose benefits aren't supported by evidence. While the per-pill cost may not be much, he said he hopes that if these patients stopped taking ineffective OTC remedies they would be more compliant with prescribed treatments that have a proven benefit. “That would be a significant step in the right direction,” he said.
As part of the new initiative, the ACP will also make changes to the next edition of its Medical Knowledge Self-Assessment Program (MKSAP). The upcoming MKSAP edition will include a focus on optimal diagnostic and treatment strategies, based on considerations of value, effectiveness, and avoidance of overuse and misuse. The ACP also plans to develop patient education materials and curricula for medical students and residents.
Because the initiative is a high priority for the ACP, the organization will initially fund the effort entirely through its own operating funds. However, Dr. Weinberger said they hope to get outside funding as the initiative is expanded to develop curricula for medical schools and residency programs.
The effort should compliment comparative effectiveness research being conducted by the Agency for Healthcare Research and Quality, according to Dr. Shekelle. Ideally, the AHRQ will develop the evidence base and the ACP will disseminate practical recommendations and guidelines, he said.