Are docs 'Choosing Wisely'?

WASHINGTON — Challenged to list several questionable procedures that are commonly used in their field, America's joint surgeons came out against custom shoe inserts and two types of dietary supplements.

They also discouraged the long-term use of wrist splints after carpal tunnel surgery and an infrequently performed procedure in which doctors wash a painful knee joint with saline.

These choices share one thing: None would significantly affect a surgeon's income.

"They could have chosen many surgical procedures that are commonly done, where evidence has shown over the years that they don't work or where they're being done with no evidence," said Dr. James Rickert, an assistant professor of orthopedic surgery at Indiana University. "They chose stuff of no material consequence that nobody really does."

As part of the nationally touted Choosing Wisely campaign, 54 medical specialty societies have each offered recommendations of at least five tests or procedures that doctors and patients should approach with skepticism. The effort is aimed at reducing unwarranted tests and treatments that rack up costs without improving the health of patients and, in some cases, actually harming them.

The lists have been distributed to more than a half-million doctors since 2012, and some participating hospitals report seeing a drop in the frequency of superfluous procedures.

Some specialty groups listed tests or procedures that have been lucrative for their members, including the gastroenterologists, radiologists and clinical pathologists. The Society of General Internal Medicine recommended against the annual physical exam, a mainstay of American health care.

But the American Academy of Orthopaedic Surgeons, based in northwest suburban Rosemont, is among those that focused on rarely used services or ones that are done by practitioners in other fields — choices that would have little impact on their earnings.

These groups "were willing to throw someone else's services into the arena, but not their own," said Dr. Nancy Morden, a researcher at the Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire.

When Morden analyzed the first 26 Choosing Wisely lists, she found that less than 20 percent of the items involved physician services. The rest targeted radiology, medications and cardiac and lab tests, Morden wrote this year in the New England Journal of Medicine.

For example, Rickert noted that discouraging dietary supplements would affect health stores and other retail outlets, not surgeons. Both he and Morden said saline injections are seldom used to treat knee pain. Morden said a search of 2011 Medicare billing records for that procedure yielded zero claims.

"That's how pathetic that item is," she said.

Dr. Augusto Sarmiento, a former president of the orthopedic academy and retired chairman of orthopedics at the University of Miami Medical School, said more significant overused procedures include replacing hips and knees when the patient's pain is minimal and can be managed with medicine.

In addition, Sarmiento said too many surgeons operate on simple fractured collarbones, inserting metal plates, rather than letting the injury heal with the help of a sling. "The abuse of surgery is due to the overwhelming control of the profession by the implant manufacturing companies," he said.

The orthopedic academy defended its selections, writing in a statement that "our recommendations are limited by the existing evidence regarding the effectiveness of various treatment options for musculoskeletal conditions, which we are seeking to improve." It noted that its recommendation against the dietary supplements could save patients $750 million a year spent on these drugs.

Other specialty groups said they did not include certain procedures where concerns of overuse exist, such as stents for heart patients and spine surgery, because the evidence is murky and the procedures are right for some patients.

The American College of Cardiology, based in Washington, D.C., opted to list the use of cardiac testing in four circumstances. But the college did not tackle what studies suggest is the most frequent type of overtreatment in the field: inserting small mesh tubes called stents to prop open arteries of patients who are not suffering heart attacks, rather than first prescribing medicine or encouraging a healthier lifestyle.

As many as 1 of 8 of these stent procedures should not have been performed, according to a study in Circulation, the journal of the American Heart Association. At hospitals where stenting was most overused, 59 percent of stents were inappropriate, the study found.

"Let's face it, angioplasty and stenting is a big business, it's highly profitable for hospitals, and it's highly remunerative for physicians," said Dr. William Boden, a New York cardiologist who oversaw the first large trials that found no advantage for stents for patients who are not in acute distress. "There's a tremendous impetus to not rock the boat and not to call attention to the fact that we do too many procedures in stable patients for whom outcomes would be the same if not even better if treated medically."

Dr. William Zoghbi, a Houston cardiologist who was president of the cardiology group when the list was announced in 2012, rejected the suggestion that stenting procedures should have been more broadly questioned, saying the vast majority of stents "are quite appropriate for the condition." He said cautious choices for the initial list made sense because a campaign like Choosing Wisely is unfamiliar to doctors. "You have to walk before you run," Zoghbi said.