How primary care physicians can improve health and lower costs

Ok, I confess. I have contributed to the $2.3 trillion that our country spends on health care every year. As a patient I want the best possible care for my family and me. As a physician I am the gatekeeper to expensive procedures, medications, and diagnostic tests. However, by several indices including life expectancy, infant mortality rate, and satisfaction with the health care system, we are not getting our money’s worth.

As discussed ad nauseum during the health reform debate, we can point the finger at any number of parties for the high cost of care: hospitals, the pharmaceutical industry, insurance companies, and patients. I would also add to that list health care providers.

Every physician that I know makes medical decisions with the patient’s best interest in mind. But conscious or not, there are competing influences. Patients may demand a particular medication they heard about from a friend or TV commercial. A drug representative may suggest the physician prescribe their drug over a cheaper medication that works just as well. A provider may order a few extra tests not because it is supported by evidence but out of fear of being sued. A procedure may be performed more often than medically indicated because it brings revenue to the practice.

The overwhelming direction is toward more care and higher costs. As much as 30% of all health care spending is estimated to go to unnecessary care. The other problem in this situation (and in a lot of others I can think of) is that more is not always better. In fact, more care can cause harm. The overuse of antibiotics have contributed to the rise in drug resistant bacteria that now make even simple infections harder to treat. The repetitive use of x-rays and CTs increase the risk of cancer particularly in children. Painful testing and potentially harmful procedures are often performed even when the results will not change the condition’s management.

So what should health care providers do differently?

The Archives of Internal Medicine recently published a study conducted by the National Physicians Alliance on the “Top 5” things primary care physicians can do to improve the health of their patients by reducing health care costs. Through a series of discussions, groups of pediatricians, family physicians, and internists each developed a list of five evidence based recommendations that if followed would get more value out of health care dollars. This was followed by review and feedback from 255 physicians in these specialties.

Few of the recommendations are surprising and frankly most are considered standard of care practices. Throat infections should test positive for streptococcus prior to prescribing antibiotics. Doctors shouldn’t order annual EKGs or any other cardiac screening for low-risk patients who don’t have symptoms.

Hopefully, initiatives such as these will help physicians provide both better care and serve as better stewards of our nation’s health care dollars.

Top 5 Internal Medicine

Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.
Screening: Don’t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in healthy adults who don’t have symptoms.
EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.
Bone Density: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

Top 5 Pediatrics

Throat Infections: Don’t prescribe antibiotics for pharyngitis (sore throat) unless the patient tests positive for streptococcus (Strep throat).
Head Injuries: Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.
Fluid in the Middle Ear: Don’t refer otitis media with effusion early in the course of the problem.
Cold Medications: Advise patients not to use cough and cold medications.
Asthma: Use inhaled corticosteroids (a steroid medication) to control asthma appropriately.

Top 5 Family Medicine

Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.
Sinusitis: Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis (inflammation of the sinuses) unless symptoms – which must include purulent (full of pus) nasal secretions AND maxillary (upper jaw bone) pain or facial or dental tenderness to percussion – last for 7 days OR symptoms worsen after initial clinical improvement.
EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
Pap smears: Don’t perform Pap tests on patients younger than 21 years or in women have had a hysterectomy for benign disease.
Bone scans: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

[In full disclosure, I serve on the Board of Directors of the National Physicians Alliance and am a member of the pediatrics working group for this study.]

Ricky Y. Choi is a pediatrician who blogs at SFGate and reprinted with the author’s permission.

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