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Weighty talks about wise choices
A new campaign urges pathologists to be the voice of caution on test orders
Article first published online: 13 JUN 2013
Copyright © 2013 American Cancer Society
Volume 121, Issue 6, pages 277–278, June 2013
How to Cite
Nelson, B. (2013), Weighty talks about wise choices. Cancer Cytopathology, 121: 277–278. doi: 10.1002/cncy.21318
- Issue published online: 13 JUN 2013
- Article first published online: 13 JUN 2013
In April 2012, a collaborative effort led by the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports keyed in on what analysts are increasingly viewing as a major weakness of the US health care system: unnecessary or inappropriate tests and procedures.
The Choosing Wisely campaign, as it was dubbed, led multiple medical specialty groups to develop recommendations, titled “Five Things Physicians and Patients Should Question.” This February, the American Society for Clinical Pathology (ASCP) released its own list of initial recommendations. John Tomaszewski, MD, past president of ASCP, says the idea is to cull tests that add no clinical value or lead doctors down the wrong path. “I think we just wanted to start that mantra of ‘right patient, right time, right test,'” says Dr. Tomaszewski, chair of the department of pathology and anatomical sciences at the School of Medicine and Biomedical Sciences at the University at Buffalo in New York.
But will it work? Several prominent pathologists expressed strong support for the effort, although they say subsequent educational and enforcement efforts likely will be necessary to produce lasting change. “I think that the Choosing Wisely campaign is excellent,” says Edward Ashwood, MD, president and CEO of ARUP Laboratories, a Salt Lake City–based national reference laboratory operated as a nonprofit enterprise by the University of Utah. “Medicine needs to do these kinds of things. I'm thrilled that ASCP weighed in.”
Due to some high-profile lawsuits in the past, Dr. Ashwood believes many pathologists are reluctant to tell clinicians they don't need certain tests. But with a laboratory menu that now includes more than 3000 individual test options, he says, “Docs need our help. [Pathologists] have to step up to the plate and practice medicine. It's our duty.”
Laurette Geldenhuys, MD, professor of pathology at Dalhousie University in Halifax, Nova Scotia, Canada, and past president of the Canadian Association of Pathologists, says she was “delighted” to hear about the new campaign. “I think it's great for someone to start somewhere,” she says. “I'm excited to see what's being done.” Similar to other pathologists, she agrees that many more tests could be added to the published list. “But probably to start off a campaign, identifying 5 key areas might be more effective than coming up with a list of 50 that would just overwhelm people,” she says.
Lee Hilborne, MD, MPH, professor of pathology and laboratory medicine at the David Geffen School of Medicine at University of California Los Angeles and a leading force behind ASCP's involvement, expects to see more questions emerge in the future. But first, he says, the association wants to make sure it understands how the process will be received. “It's our hope to really look at more and more tests and come out with more and more information to help guide the physicians to better use the tests,” he says.
The ASCP's Institute Advisory Committee, with Dr. Hilborne at the helm, combed through the literature and identified hundreds of potential candidates for inclusion before winnowing down the list. Instead of selecting the most frequently ordered tests, however, the committee selected ones that would illustrate specific clinical concerns.
Dr. Hilborne says one recommendation, against performing low-risk human papillomavirus (HPV) testing, is an example of a good test with no clinical value because low-risk HPV is not associated with cancer progression. “There's no benefit,” he says. “So, if you're not going to do something with the test, then there's no reason to perform it.”
Another test, for 25-hydroxy vitamin D deficiency, is good and has clear indications, but the committee recommended that clinicians forgo general population-based screening in favor of more targeted testing of higher risk patients. An advisory against using the bleeding time test, in contrast, illustrates a subpar test for which better alternatives exist. And a directive to avoid routine preoperative testing for low-risk surgeries without a clinical indication was included to remind clinicians that no benefit accrues from testing patients lacking risk factors.
The final entry, the test for methylated septin 9 DNA, which is associated with colorectal cancer, is not a substitute for a colonoscopy and does not perform any better than alternative tests despite costing considerably more money. The ASCP committee added it to the list as an example of a molecular diagnostic test. Dr. Tomaszewski says a reality check could be especially important for this increasingly prevalent—and costly—category of tests, lest they be inappropriately ordered by clinicians. “They can spend tens of thousands of dollars in the blink of an eye,” he says.
Toolkits, Roadblocks, and Peer Pressure
Both Dr. Hilborne and Dr. Tomaszewski stress that a major intent of the guidelines is to expand the message beyond pathologists, most of whom are already aware of best practices. “If all we did was to discuss it as pathologists, there wouldn't be much benefit because the pathologists aren't the people who order the tests,” Dr. Hilborne says. Instead, he sees the goal as empowering pathologists and other laboratory professionals to actively engage in constructive dialogues with other clinicians.
That's not always an easy conversation to have. Aided by a $50,000 grant from the ABIM Foundation, the ASCP will set up an educational symposium with the California Association of Pathologists (CAP) as a potential model for how to help pathologists and laboratory professionals communicate more effectively with their colleagues and patients. Robert Achermann, executive director of CAP, says the first phase of the joint educational effort will occur at the state society's annual meeting in December, with continuing education and more tools likely to follow.
Pathologists are increasingly likely to interact with additional health care providers who may be less experienced or knowledgeable about laboratory test utilization, Achermann says. “Especially in California, we're seeing more and more nonphysician practitioners entering the health care delivery system, and that education component becomes even more important,” he says.
As some laboratories have learned, the education may have to be supplemented with proactive measures. ARUP Laboratory's well-established ATOP (Analyzing Test Ordering Patterns) analytical service exists in large part to help clinicians reduce unnecessary and wasteful ordering. The laboratory created a second tool called ARUP Consult, that incorporates a Web site and mobile app, specifically for ordering physicians.
But because passive mechanisms can only go so far, Dr. Ashwood says, ARUP Laboratory is also setting up active roadblocks for options such as the low-risk HPV test on ASCP's Choosing Wisely list. “If somebody does order it, they're going to get a phone call back from us, saying, ‘You realize this is no good for cervical cancer screening? It only has these indications; does the patient have one of these?' We're going to try to talk them out of it,” he says. Some doctors may react angrily to being second-guessed, but Dr. Ashwood says many are likely to be grateful for the guidance.
Dr. Geldenhuys agreed that effective communication can be a “huge challenge.” After clinicians largely ignored memos about best practices, she says, her hospital integrated several checks directly into the ordering process and test results. Under one mechanism known as test cancellation, any physician who tries to order a second test too soon after the first, when an additional result would prove meaningless, is unable to do so.
Within every negative Papanicolaou test result, the hospital's cytopathology laboratory also includes a reminder in capital letters that the next one should be done in 2 years, rather than in 1 year, unless the patient has an indication to be tested more frequently. As a result, the laboratory is seeing a significant decrease in test orders.
Several pathologists agreed that electronic health records and informatics, if used properly, could help laboratories collect and analyze test-ordering data to improve practices. Even simple peer pressure might do the trick. “We are planning to share physician-specific information that says, for example, that they are ordering far more frequently than is recommended, or than their peer group,” Dr. Geldenhuys says. “Often, just the knowledge by individual physicians that they are an outlier within their peer group could be sufficient to modify their ordering behavior.”
And that added note of physician caution, pathologists say, would be a welcome sign of change.