By Dr. Paul Ehrlich
This morning, the Monday after Easter, I was jolted to attention on the way to the office by my regular Starbucks and by an editorial that began: “If health care costs are ever to be brought under control, the nation’s doctors will have to play a leading role in eliminating unnecessary treatments. By some estimates, hundreds of billions of dollars are wasted this way every year. So it is highly encouraging that nine major physicians’ groups have identified 45 tests and procedures (five for each specialty) that are commonly used but have no proven benefit for many patients and sometimes cause more harm than good.”
A couple of clicks on the online version brought me to this list, compiled by the AAAAI (first alphabetically on the roster of specialties):
1. Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy. Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment. Appropriate diagnosis and treatment is both cost effective and essential for optimal patient care.
2. Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis. Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinsutis.
3. Don’t routinely do diagnostic testing in patients with chronic urticaria. In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.
4. Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.Immunoglobulin (gammaglobulin) replacement is expensive and does not improve outcomes unless there is impairment of antigen-specific IgG antibody responses to vaccine immunizations or natural infections. Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin. 5. Don’t diagnose or manage asthma without spirometry. Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.
I can’t argue with this list. Item number one—those unproven IgG tests and indiscriminate use of IgE tests are right up there for me. I provided allergy services to a large group practice in one of New York’s fair boroughs for some time until the practice controller noticed that I wasn’t routinely ordering the full panel of 60 tests that insurance ordinarily covered. Decades of clinical practice had taught me to winnow the long lists based on a good history. This emphasis on the bottom line made that a bad fit for me. In addition, there is the problem of over-diagnosing food allergies based on test results, which results in unwarranted worry and food avoidance.
As for inappropriate use of antibiotics for most rhinosinusitis, “this too shall pass” is the height of medical wisdom. When patients demand “results” in the form of a prescription, we should resist. And so on for items three through five.
We are faced with these and other issues every day in practice. Another big one for me is when to recommend immunotherapy, and what kind. Patients with mold allergies may be desperate for relief, but I counsel against it unless it is combined with other allergens because it’s not all that effective, and not worth the weekly or monthly shot on its own. Spending the money to ventilate or seal the basement or fix the roof is a much better idea. Many allergists have jumped on the bandwagon for sub-lingual immunotherapy—SLIT as it’s called—which is easier than shots, particularly for small children. Yes, but it is also not proven for a broad range of allergens and for the one where it is somewhat effective, it is less effective than shots.
The value of any doctor lies both in knowledge and in wisdom. We should not prescribe tests just, as some suggest we do, to cover our behinds in a litigious society. Neither should we prescribe tests and treatment just to cover our expenses. Treating patients means saying no as well as yes.