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Many common medical tests and treatments are unnecessary

Learn when to say ‘Whoa!’ to your doctor

Consumer Reports magazine: June 2012

Doctors often order tests and recommend drugs or procedures when they shouldn’t—sometimes even when they know they shouldn’t. In fact, nearly half of primary-care physicians say their own patients get too much medical care, according to a survey published in 2011 by researchers at Dartmouth College. And the Congressional Budget Office says that up to 30 percent of the health care in the U.S. is unnecessary.

All that unneeded care can be hazardous to your health—and your wallet. For example, X-rays and CT scans expose you to potentially cancer-causing radiation, and can lead to follow-up tests and treatment with additional risks. And the costs can be substantial. A 2011 study found that the price tag for 12 commonly overused tests, such as annual electrocardiograms (EKGs) for heart disease and imaging tests for lower-back pain, was about $6.8 billion.

The problem has become so serious that such groups as the American College of Physicians, the ABIM Foundation, the National Physicians Alliance, and a coalition of medical societies in a project called Choosing Wisely have compiled lists of tests and treatment doctors themselves say are done too often. Below are our top five examples culled from those lists. (For more information, read Choosing Wisely: How to avoid unnecessary tests and treatments.)

EKGs and exercise stress tests for heart disease

The problem: For many people, an EKG—which records the heart’s electrical activity through electrodes attached to the chest—is a standard part of a routine exam. Some also regularly get an exercise stress test, which is an EKG done as they walk on a treadmill. Both are key if you have symptoms of heart disease or are at high risk of it. But for other people, the tests are not as accurate and can lead to unnecessary follow-up and treatment.

The risks: Those follow-up tests can include CT angiograms, which expose you to a radiation dose equal to 600 to 800 chest X-rays, and coronary angiography, which exposes you to further radiation. Inappropriate testing can also lead to overtreatment with drugs or even surgery.

The costs: An EKG typically costs about $50 and an exercise stress test about $200 to $300, according to the HealthCareBlueBook.com. Subsequent interventions that are prompted by unneeded tests can add thousands to the tab.

When to consider the tests: An EKG and exercise stress test should often be ordered if you have chest pain, an irregular heartbeat, or other symptoms of heart disease. They can also make sense for people with diabetes or other coronary risk factors who are just starting to exercise. (See our advice on preventing, detecting, and treating heart disease and use our calculator to estimate your risk of having a heart attack in the next 10 years.) 

Imaging tests for lower-back pain

The problem: Getting an X-ray, CT scan, or MRI can seem like a good idea. But back pain usually subsides in about a month, with or without testing. Back-pain sufferers in a 2010 study who had an MRI within the first month didn’t recover any faster than those who didn’t have the test—but were eight times as likely to have surgery, and had a five-fold increase in medical costs.

The risks: One study projected 1,200 new cancer cases based on the 2.2 million CT scans done for lower-back pain in the U.S. in 2007. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes including even surgery.

The costs: An X-ray of the lower back typically ranges from about $200 to $285, an MRI from $875 to $1,225, and a CT scan from $1,080 to $1,520. Imaging accounts for a big chunk of the billions Americans spend for lower-back pain each year.

When to consider the tests: They often make sense if you have nerve damage, or signs of a serious underlying condition. Red flags can include a history of cancer, unexplained weight loss, recent infection, loss of bowel control, urinary retention, or loss of leg strength. (See our advice on treating lower-back pain.)

CT scans and MRIs for headaches

The problem: Many people want a CT scan or MRI to see if their headache is caused by a brain tumor or other serious illness. And doctors often comply to provide reassurance and to avoid lawsuits. But all that’s usually needed is a careful medical history and neurological exam. Adding a CT scan or MRI rarely helps.

The risks: Brain scans can reveal things that appear worrisome but aren’t. For example, doctors might mistake a twist in a blood vessel for an aneurysm. Those findings can trigger follow-up tests, and prompt referrals to specialists for expensive consultations. And CT scans of the head can deliver a radiation dose that’s the equivalent of 15 to 300 chest X-rays.

The costs: A standard brain CT scan costs about $340, and a brain MRI about $660. Referrals to a specialist or subsequent treatment is extra, of course.

When to consider the tests: They’re often warranted if you have an abnormal result on a neurological exam, or if your doctor can’t diagnose the problem based on your symptoms and medical exam. See a doctor if you have head pain that is sudden or explosive; different from headaches you’ve had in the past; brought on by exertion; or accompanied by fever, a seizure, vomiting, loss of coordination, or a change in vision, speech, or alertness. (See our advice on treating headaches.)

Bone-density scans for low-risk women

The problem: Many women are routinely screened for weak bones with an imaging test called a DEXA scan. If it detects outright osteoporosis, the results can help you and your doctor decide how to treat the problem. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.

The risks: A diagnosis of osteopenia often leads to treatment with such drugs as alendronate (Fosamax) and ibandronate (Boniva), which pose numerous risks. Those include thigh fractures, throat or chest pain, difficulty swallowing, heartburn, and more rarely, bone, eye, joint and muscle pain, bone loss in the jaw, and possibly, abnormal heart rhythm. But there is little evidence that people with osteopenia benefit from the drugs.

The costs: A DEXA scan costs about $132. The price for a month’s supply of generic alendronate is $38 to $70, and $125 to $148 for Fosamax, the brand-name version. People often take the drugs for years.

When to consider the test: Women should have the scan at age 65 and men at age 70. Younger women and men ages 50 to 69 should consider the test if they have risk factors such as a fracture from minor trauma, rheumatoid arthritis, low body weight, a parent who had a hip fracture, or if they have used corticosteroid drugs for a long time, or they drink excessively or smoke. Whether follow-up tests are needed depends on the results of the initial scan. (See our advice on treating osteoporosis.)

Antibiotics for sinusitis

The problem: People with sinusitis—congestion combined with nasal discharge and facial pain—are often prescribed antibiotics. In fact, 15 to 21 percent of all antibiotic prescriptions for adults are to treat sinusitis. But most people don’t need the drugs. That’s because the problem almost always stems from a viral infection, not a bacterial one—and antibiotics don’t work against viruses.

The risks: About one in four people who take antibiotics report side effects, such as a rash, dizziness, and stomach problems. In rare cases, the drugs can cause anaphylactic shock. Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.

The costs: Not all antibiotics are expensive, but since doctors write so many prescriptions for them, the total cost to the health-care system is substantial—at least $31 million a year.

When to consider antibiotics: Usually only if symptoms last longer than a week to 10 days or they are accompanied by a high fever or other possible signs of a bacterial infection. (See our advice on treating sinsusitis.)

Ask these questions

Do I really need this test or procedure? The answer should be direct and simple. Tests should help you and your doctor decide how to treat your problem, and procedures should help you live a longer, healthier life.

What are the downsides? Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.

Are there simpler, safer options? Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing? Ask if your condition might worsen—or get better—if you don’t have the test or procedure now.

How much does it cost? Ask whether there are less expensive alternatives, or generic versions of brand-name drugs.

Why do doctors provide unnecessary care?

One reason is that patients, motivated perhaps by an ingrained belief that more care is always better care—not to mention ads from drug companies—ask for it. And all too often doctors comply, in part because it’s faster and easier than explaining why a test or drug might not be a good idea.

Of course, doctors have other motivations, too, including financial ones. For example, research suggests that those who invest in imaging equipment order more CT scans and MRI tests than doctors who haven’t made the investment. Some doctors say they practice aggressively to protect themselves from lawsuits. More than 80 percent of primary-care doctors in our 2010 survey said the need to practice defensive medicine interfered with their ability to provide optimal care.

A reason doctors are less likely to own up to: It’s hard to kick bad habits. But researchers say that doctors often embrace evidence that reinforces their practice style while ignoring evidence that conflicts with it. For example, results from a trial published in 2007 found that angioplasty—an invasive procedure— worked no better than drugs plus lifestyle changes for people with stable heart disease. But several years later a study found that most doctors still chose angioplasty without giving those simpler, less expensive steps a shot first.
Editor's Note: A version of this article appeared in the June 2012 issue of Consumer Reports magazine with the headline "When to Say ‘Whoa!’ to Your Doctor."

   

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