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Making Practice Guidelines And ‘Choosing Wisely’ More Effective

Making Practice Guidelines And ‘Choosing Wisely’ More Effective

A young female doctor consults with a senior

I always thought I was an informed patient, favoring conservative treatment and helping to save Medicare and the health system money; but when push came to shove, I was a coward that did not speak up when unnecessary tests were ordered.

I think my reaction says something about the limits that even informed patients have in their ability to save the system money and ultimately raises questions about the usefulness of practice guidelines, “choosing wisely,” and evidence-based medicine to do the same. This isn’t an attack on these crucial efforts to bring more science to the practice of medicine. It is a plea for them to be more effective.

As a personal example, when my eye doctor and I agreed it was time for cataract surgery, I signed up with a well-known, large-volume surgeon at his practice in Northern Virginia. In the middle of the elaborate, pricey process, I was given a pre- and post-surgical package. It included a form that required that before surgery the practice should receive a statement from my primary care physician with the results of a timely blood analysis and an EKG, even though I do not display any obvious morbidity warning signs—my blood pressure, BMI, and so forth are all very good.

When I saw the form, I remembered—vaguely—that Cochrane and other advocates of evidence-based medicine had stated that most of the time those tests (and their costs) were not necessary pre-cataract surgery. But I didn’t say anything to the eye surgeon, despite knowing this information. I thought of my wife: She never sends food back at a restaurant for fear of being a troublemaker. Troublemakers do not get good service. I wondered if I should become a troublemaker to this surgeon, but ultimately I went along with his request.

Not wasting time by requiring preoperative tests for patients not at major risk of complications is the first item in the American Academy of Ophthalmology’s “Choosing Wisely” campaign. The tests also are unnecessary according to the Cochrane Library literature reviews. However, the recommendation to generally not test is clearly very widely ignored—and has been for a very long time. There was a 2015 study that noted “…since 2002, guidelines from multiple specialty societies have deemed routine preoperative testing necessary…. Our [study] results showed no difference in the prevalence of testing as compared with 20 years ago….. [Our] data underscore the fact that publishing evidence-based guidelines alone does not necessarily change individual physician behavior.” The paper found that about 53 percent of…

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