Making wiser choices about medical tests and treatments

- Kenny Lin, MD

The July 15th issue of AFP features an special online editorial by AFP editor Jay Siwek, MD that compiles family medicine-relevant items from the multi-specialty Choosing Wisely campaign that aims to reduce the provision of "unnecessary" care, defined as medical tests and treatments that offer no health benefits and may result in harm to patients. Based on trusted sources of evidence-based medicine such as the U.S. Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus, these "don't do" recommendations have the potential to save both lives and money, if they can be effectively put into practice. To inform patients about the campaign, Consumer Reports has created fact sheets about many of the included items.

Reactions to the Choosing Wisely campaign in the blogosphere have been varied. Calling it "the health reform we need," cardiologist John Mandrola writes, "I hope it sticks like super glue." On the other side, emergency physician William Sullivan argues that the campaign "has good intentions, but isn't a good idea," noting that "there isn’t a Suing Wisely campaign for attorneys and there isn’t a Legislating Wisely campaign for Congress." Similarly, family physician Mike Sevilla contends that while Choosing Wisely may "score political points" for sponsoring physician organizations, it is unlikely to change their members' behavior, which is also driven by patient demands and fears of lawsuits over interventions not taken. Where do you stand on this spectrum? Is the Choosing Wisely campaign good or bad for family medicine, or perhaps some of both?

Which test should be used for TB screening?

- Kenny Lin, MD

The tuberculin skin test has a long and venerable history as the screening test of choice for latent tuberculosis infection in the United States. A 2009 AFP article called it "the most acceptable method" of tuberculosis screening. However, the tuberculin skin test has limitations: it requires 2 patient visits, and may be difficult to interpret in persons from other countries that have received bacille Calmette-Guerin (BGC) vaccinations. In contrast, interferon-gamma release assays (IGRAs) performed on blood samples require only a single patient visit, do not cross-react with BCG, and according to a recent systematic review, have comparable specificity to TSTs. The Centers for Disease Control and Prevention now recommends that IGRAs be the preferred test for patients with prior BCG vaccinations and those who are unlikely to return for a TST reading (e.g. homeless persons). But why not go one step further and abandon the tuberculin skin test entirely?

In an editorial in this week's JAMA, Drs. Phillip LoBue and Kenneth Castro examine the case for replacing traditional skin with blood tests for tuberculosis. They note that although the evidence is limited, positive IGRAs are able to predict which patients will eventually develop active tuberculosis in the absence of treatment at a rate similar to TSTs, albeit poorly (5 to 10 percent). It is also uncertain if having a single positive cutoff value for IGRAs will produce additional false-positive results, compared to the 3 values for a positive TST based on a person's health status and tuberculosis risk. Finally, an IGRA costs 3 times as much as TST, even factoring in costs associated with a follow-up visit.

What test or tests does your practice currently use to screen patients for latent tuberculosis infections? Do you think the convenience and ease of interpretation of the blood test is worth the additional cost? Please let us know your thoughts.

Electronic health records may improve preventive care

- Kenny Lin, MD

In an editorial in the May 15th issue of AFP, I summarized the mixed evidence that using electronic health records with clinical decision support systems (CDSSs) improves processes and outcomes of preventive care. Most of the literature supporting a positive effect of EHRs with CDSSs is either anecdotal, observational, or limited to specific settings (namely, practices of employed physicians in large, integrated health systems). I concluded that it remained uncertain if these results could be duplicated in randomized trials in typical private practices.

Uncertain, that is, until this week, following a study by Alex Krist and colleagues, "Interactive Preventive Health Record to Enhance Delivery of Recommended Care: A Randomized Trial," in the Annals of Family Medicine. The authors randomized 4500 patients from 8 primary care practices in Virginia to usual care versus an invitation to use MyPreventiveCare, an interactive personal health record (IPHR) that generates a list of screening and counseling recommendations based on guidelines from the U.S. Preventive Services Task Force, as well as links to more detailed explanations of these preventive services and relevant decision aids. When patients used the IPHR, their physicians also received a summary of the recommendations in their EHRs.

Although only about 1 in 6 invited patients had actually used the personal health record 16 months later, it was enough to show a statistically significant difference between the proportion of patients in that group who were up-to-date on all recommended services, compared to the control group. After 4 months, colorectal, breast, and cervical cancer screening rates had increased by an impressive 13 to 19 percent among personal health record users. The authors concluded: "Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits." A how-to guide on the use of personal health records to promote preventive services is available on the Agency for Healthcare Research and Quality website.