Routine testing for prostate cancer, urinary tract infections, and blood sugar levels can lead to unnecessary care and serious health problems. The practices stubbornly persist despite a lack of evidence. The study effectively reduced doctors’ actions for overused tests and treatments.
Summary Reduce overuse of care in older patients through professional standards and accountability. A cluster randomized controlled trial Background: Effective strategies are needed to limit overuse that can cause harm. Aim: To evaluate the effects of physician decision support in redirecting attention to harms and addressing social and reputational concerns about overuse in older primary care patients. Design: Pragmatic, cluster-randomized, restricted randomization trial of 18 months duration. (ClinicalTrials.gov: NCT04289753) Setting: 60 primary care internal medicine, family medicine and geriatric consultations within a health system from September 1, 2020 to February 28, 2022. Participants: 371 primary care physicians and their older adult patients from participating offices. Intervention: Behavioral science-based, point-of-care clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes were compared (187 clinicians from 30 clinics) with brief case-based education alone (187 doctors from 30 clinics). Decision support was designed to raise the salience of potential harms, convey social norms, and promote accountability. Measurements: Prostate-specific antigen (PSA) testing in men 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients 75 years and older and hemoglobin A. 1c (HbA 1c) less than 7%. Results: At the time of randomization, the mean annual rates of clinical PSA testing, unspecified urine testing, and diabetes overtreatment were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted differences in annual rates of PSA testing (−8.7 [95% CI, −10.2 to −7.1]), urine testing unspecified (−5.5 [CI, −7.0 to −3.6]) and diabetes overtreatment (−1.4 [CI, −2.9 to −0.03]) compared with education only . Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA 1c greater than 9.0% was more common with the intervention among previously overtreated patients with diabetes (adjusted differences in differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). Limitation: A single health system limits generalization; Electronic health data limits the ability to differentiate between excessive testing and lack of documentation. Conclusion: Decision support designed to increase clinicians’ attention to potential harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment can also lead to higher rates of uncontrolled diabetes. |
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CHICAGO --- When a doctor ordered a routine prostate exam for an 80-year-old man, as doctors often do, a dramatic yellow alert appeared in the electronic medical record with warnings. He flashed: “He is requesting a test that no guide recommends. PSA screening can cause harm from diagnostic and treatment procedures. If you proceed without justification, the unnecessary test will be noted in the medical record.”
This was the strategy Northwestern Medicine researchers tested to see if they could change the stubbornly persistent practice of ordering unnecessary screenings for older adults. The doctors got the message.
The results, published in Annals of Internal Medicine , found a significant decrease in prostate cancer screening and urinary tract infections.
After 18 months of sending alerts to 370 doctors at 60 Northwestern Medicine clinics, unnecessary testing was reduced by 9% in the PSA intervention group and 5.5% in the urine testing intervention group . However, there was only a small change in the overtreatment of blood sugar, which can also lead to potential harm. Half of the doctors received the alerts, the other half did not.
"To our knowledge, this is the first study to significantly reduce all unnecessary tests or treatments studied using point-of-care alerts," said lead researcher Dr. Stephen Persell, a professor of medicine at the Feinberg School of Medicine in New York. Northwestern University and a Northwestern Medicine physician. "We believe that incorporating elements such as focusing on potential harms, sharing social norms, and promoting a sense of social responsibility and reputational concerns led to the effectiveness of these messages."
Several recent trials that attempted to reduce overuse of testing through interventions delivered to doctors through electronic medical records have not had much success in changing doctors’ behavior, Persell noted.
"But if messages that doctors find compelling can be conveyed through electronic medical records at the time doctors place their orders, this could be a simple way to improve care and could be easily applied across large health systems," Persell said. .
Harm from unnecessary screening and overtreatment
Screening a man 76 years or older for prostate cancer can result in overtreatment that could cause him more serious health problems than simply living with indolent cancer.
Still, a man’s primary care doctor will often obtain a PSA test to screen for prostate cancer. The same goes for women age 65 and older who are screened for urinary tract infections without any symptoms. Doctors also overtreat diabetes with hypoglycemic agents in patients 75 years of age or older.
Overuse of low-value screening and unnecessary care remains a problem in American healthcare, particularly for older adults. “These are screening practices that people have adopted without solid evidence,” Persell said.
"If a man is not going to live another 10 or 15 years because of his age, you will not save his life from prostate cancer by screening him, but you will subject him to the potential harms of treatment," said Persell, also director of the Center of Innovation in Primary Care of Feinberg. Treatment may lead to surgery or radiation therapy which may cause urinary incontinence or urinary symptoms, impair sexual function, or cause rectal bleeding.
"What’s right for a 68-year-old may not be right for a 75- or 85-year-old," Persell said.
It may also be harmful to test women aged 65 and older for urinary tract infections if they do not experience any symptoms.
"These asymptomatic urinary tract infections are common in older women, but there is no evidence that a woman’s health can be improved with antibiotics," Persell said. However, antibiotics can cause allergic reactions, diarrhea, and antibiotic resistance, which could make bacterial infections more difficult to treat in the future.
Additionally, treating blood sugar to very low levels in older adults with medications such as insulin or sulfonylureas puts older patients at risk for dangerous low blood sugar events.
But doctors and patients are reluctant to change blood sugar interventions. "We have taught patients to strive to control their blood sugar, even when there comes a point where it is safer to have a slightly less controlled blood sugar," Persell said. "It’s hard to convince patients and doctors to change their goals."
The next step in the research and other ongoing studies is to test whether similar approaches can be used to improve the quality of care in other areas where treatments such as opioids, sleeping pills, and drug combinations can be abused. Cause damage.
Other authors include Lucia C. Petito, Ji Young Lee, Daniella Meeker, Jason N. Doctor, Noah J. Goldstein, Craig R. Fox, Theresa A. Rowe, Dr. Jeffrey A. Linder, Ryan Chmiel, Yaw Amofa Peprah, and Tiffany. Brown. The title of the article is "Reducing overuse of care in older patients through professional standards and accountability." The research was supported by award R33AG057383 from the National Institute on Aging of the National Institutes of Health.
