When Dr. Michael Mooney threads a catheter inside the arteries of a heart-attack patient, he often finds an obstruction beyond the big blockage that is his main target. But, as tempting as it would be to remove the obstruction and prevent it from causing the next heart attack, Mooney follows advice from leading medical authorities to leave it and exit his patient’s circulatory system as quickly as possible.
“It can be tempting,” he said, “but restraint is clearly in the patients’ best interests.”
Restraint is the theme of a new campaign called Choosing Wisely Minnesota, which is confronting the American obsession to scan, screen and treat every medical issue whether it presents a threat to the patient or not. Leaving benign blockages behind is one of 11 recommendations organizers will make to Minnesota doctors and patients in an effort to reduce unnecessary and costly medical care.
The 11 targets — ranging from inducing labor prematurely to misusing antibiotics for sinus infections — were selected out of 135 tests and procedures that American medical associations have concluded are wasting money and putting patients at risk.
“Over the years … we’ve focused on trying to achieve certainty about a diagnosis,” said Dr. Tom Kottke, a cardiologist and HealthPartners executive who helped select the 11 procedures. “The fact of life is that diagnoses are always at least a little bit uncertain … So we have ordered lots and lots of tests without thinking about the downside, and the downside isn’t just the cost. They can actually be harmful.”
Choosing Wisely started as a national campaign two years ago and emerged in Minnesota over the past year with the help of grants to three local health care organizations, including the Minnesota Medical Association, the trade group for the state’s doctors. But efforts to educate local doctors and patients on the targeted procedures are just beginning.
On Wednesday, the campaign provided its first webinar to doctors explaining why they shouldn’t induce labor or perform surgical deliveries before 39 weeks of gestation unless it is necessary for the health of the mother or fetus.
Thursday will launch various education efforts aimed at patients, so they can make informed decisions about tests and procedures with questionable value. Included are imaging for simple headaches or back pain in the first few weeks, and certain pre-operation tests for low-risk surgeries.
“I tell my patients now that we only do tests if there is a decision to be made,” Kottke said. “I mean, why look at the map if you are already on the right road?”
Choosing Wisely members, who include doctors, health policy experts and major employers, said they don’t foresee progress unless they can get doctors and patients aligned and talking openly about their treatment goals and plans. One strategy is to hand out cards with five questions patients should ask — about the benefits, risks, costs and alternatives to tests and procedures as well as the consequences of not doing them.
Choosing Wisely is also collaborating with Consumer Reports, the publisher of respected consumer advice on everything from cars to appliances, on advice to patients on why to avoid certain tests.
A survey of Minnesota doctors found that 70 percent had been pressured by patients into performing tests or procedures they wouldn’t otherwise recommend. The Consumer Reports information should address that by giving patients extra confidence in their doctors’ restraint, said Dr. Howard Epstein of the Institute for Clinical Systems Improvement, a Bloomington health policy organization that is part of the campaign.
“It’s not always helpful [for doctors] to just say no,” he said. It’s more important to discuss the patient’s goals and preferences, he said, and ask: “How do we use effective care … and protect you from unnecessary harm and suffering?’ ”
In some cases, the recommendations may seem to run counter to logic.
In an era of heightened concern about concussions, for example, immediate imaging scans of even minor head injuries in children would seem prudent. But the Choosing Wisely campaign discourages that practice. Studies have found that imaging yields very little meaningful information for children with mild injuries — many of whom simply need rest — and exposes them to small but unnecessary levels of radiation.
“A lot of people believe more health care is better … whereas it can actually be harmful,” said Carolyn Pare, president and CEO of the Minnesota Health Action Group, which is part of the campaign and represents employers concerned with rising health costs. “There is an associated risk with having too many imaging scans.”
It would seem equally sensible for a surgeon to clean out additional blockages while working inside the arteries of heart patients. But studies show this puts additional stress on an already stressed heart muscle, and that removing additional blockages increases the risk of death or injury during a procedure.
“Most of the time, you can get away with it,” said Mooney, director of interventional cardiology at Abbott Northwestern Hospital in Minneapolis. “But when you don’t get away with it, the patient is going to be in trouble.”
Mooney said most Twin Cities cardiologists have already shifted toward this conservative approach, which was recommended by the American College of Cardiology and the American Heart Association. Instead of immediately removing blockages, the doctors review their patients’ tests and imaging scans and, if necessary, do follow up procedures before the patients leave the hospital.
Even if doctors have already adopted some of these practices, Epstein said it is important to promote them. Claims data show that some doctors still operate outside these guidelines. Elective inductions and C-sections, for example, still occur before pregnant women reach 39 weeks gestation, which increases the risk of birth defects.
“The last thing we want,” he said, “is for somebody to have something happen to them — have some bad outcome — and then realize I didn’t need that test or procedure in the first place.”