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.
The cardiologists did discourage one specific use of stenting, where doctors opening a clogged artery put additional stents in places where screenings have spotted the starts of blockage. Dr. Vikas Saini, a Massachusetts cardiologist and president of the Lown Institute, which advocates for reducing misuse of medical treatments, said: "in 20 years of practice that's not something I would have thought is standard, and if people are still doing it that's a shame."
It is unclear how many spine surgeons are still performing a procedure the North American Spine Society placed on its list: using bone growth material in spinal fusion in the neck. The Food and Drug Administration issued a safety alert about the procedure in 2008, noting that it had led to swollen neck tissue that compressed patients' airways, making it hard to breathe or speak.
"I think the use for that purpose has already fallen off substantially," said Dr. Richard Deyo, a spine researcher and a professor at Oregon Health & Science University. "They've taken on the easy things."
Dr. F. Todd Wetzel, an orthopedic surgeon at Temple University Medical School in Philadelphia who sits on the board of directors of the North American Spine Society, acknowledged the selections were cautious.
"What we did when we made up the list was to start with more straightforward situations and hopefully expand that later," Wetzel said.
The group, based in southwest suburban Burr Ridge, also did not address spinal fusion, which more than doubled in frequency between 1998 and 2008, faster than most procedures, one study showed.
Wetzel said that because spinal fusion has been shown to be useful "under very specific circumstances," the society "didn't feel comfortable making any kind of blanket statement."
The only other procedure the society mentioned on its list was spinal injections, but the suggestion would expand, not restrict, surgeons' work: It encouraged doctors to do their injections with the help of imaging, which would tack on another expense.
The importance of which items are included on the Choosing Wisely list is not just an academic debate, because where the initiative has been actively embraced the rate of those services has dropped. Dr. Donald Berwick, a former head of Medicare, heralded the Choosing Wisely campaign as "a game-changer" because the "advice comes not from payers or politicos, but from pedigreed physician groups."
Last year, the Cedars-Sinai Health System in Los Angeles added 120 Choosing Wisely recommendations into its computerized patient records so they would pop up on a screen whenever a clinician tried to authorize one. "The alerts fire about 100 times a day," said Dr. Scott Weingarten, Cedar-Sinai's chief clinical transformation officer.
As an example of the impact, Weingarten cited a decrease in the use of benzodiazepines and other sedative-hypnotics to treat the elderly. The American Geriatrics Society had recommended against those drugs because they can increase falls.
In Annapolis, Md., the Anne Arundel Medical Center broadcasts Choosing Wisely lists on hospital televisions, places posters on the walls of doctors' offices and discusses the lists in its magazine that it mails to county residents. The lists are also embedded as links in electronic patient records so physicians can easily review them.
Dr. Barry Meisenberg, an oncologist in charge of the hospital's quality efforts, said the lists are helpful when he is trying to explain to patients why he is not ordering a particular test. "It does help that's not just this guy's opinion, it actually has the imprimatur of a society," he said.
Consumer Reports, AARP and Univision are among the influential organizations that have been working to educate patients about the questionable items. Dr. John Santa, medical director for Consumer Reports, said reducing tests is a worthy goal because test results often prompt patients to get procedures.
Santa cited electrocardiograms, which are used to measure the heart's electrical activity to diagnose heart disease.
"Some people would say, it's a $50 test, it's harmless," Santa said. "The false positives you get from EKGs can cause significant downstream problems. You may think you may have just been brilliant in detecting some abnormality. That's how stents get put in."
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.Copyright © 2015, The Baltimore Sun