Reducing unnecessary testing or treatments in older patients

When a doctor ordered a routine prostate screening for an 80-year-old man -; as doctors often do -; a dramatic yellow alert popped up on the electronic health record with dire warnings. 

It flashed: "You are ordering a test that no guideline recommends. Screening with PSA can lead to harms from diagnostic and treatment procedures. If you proceed without a justification, the unnecessary test will be noted on the health record." 

This was the strategy Northwestern Medicine investigators tested to see if they could move the needle on the stubbornly persistent practice of ordering unnecessary screenings for older adults. Doctors got the message.

The results, published Feb. 6 in Annals of Internal Medicine, found a significant decrease in screenings for prostate cancer and urinary tract infections. 

After 18 months of delivering the alerts to 370 clinicians in 60 Northwestern Medicine clinics, unnecessary testing was reduced 9% in the PSA intervention group and 5.5% in the urine testing intervention group. There was, however, only a small change, in the overtreatment of blood sugar, which also can result in potential harm. Half of the physicians received the alerts, the other half did not. 

To our knowledge, this is the first study to significantly reduce all of the unnecessary testing or treatments studied using point-of-care alerts. We believe that incorporating elements like a focus on potential harms, sharing social norms and promoting a sense of social accountability and reputational concerns led to the effectiveness of these messages."

Dr. Stephen Persell, lead investigator, professor of medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician

Several recent trials that attempted to reduce overuse of testing, using interventions delivered to clinicians through the electronic health record, have not been particularly successful at changing clinicians' behavior, Persell noted. 

"But if messages clinicians find compelling can be delivered by electronic health records at the time clinicians place their orders, this could be a straightforward way to improve care and could be applied across large health systems easily," Persell said. 

Harm from unnecessary screening and overtreatment

Screening a man 76 years or older for prostate cancer may result in overtreatment that could cause him serious health problems than simply living with an indolent cancer.

Even so, a man's primary care physician will often obtain a PSA test to screen for prostate cancer. Ditto for women 65 and older being tested for urinary tract infections without any symptoms. Doctors also overtreat diabetes with hypoglycemic agents in patients aged 75 years and older.

The overuse of low-value screenings and unnecessary care remains a problem in American health care, particularly for older adults. 

"These are screening practices people have adopted without good evidence," Persell said. 

"If a man is not going to live another 10 or 15 years due to his age, you won't 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 for Primary Care Innovation at Feinberg. The treatment may lead to surgery or radiation treatment that can cause urinary incontinence or urinary symptoms, impair sexual function or cause rectal bleeding. 

"What's right for a 68-year-old man might not be right for one who is 75 or 85 years old," Persell said. 

Harm can also result from testing women 65 and older for urinary tract infections, if they are not experiencing any symptoms.

"These asymptomatic urinary tract infections are common in older women, but there is no evidence that you can improve a woman's health with antibiotics," Persell said. Antibiotics, however, can cause allergic reactions, diarrhea and antibiotic resistance, which could make bacterial infections harder to treat in the future.

In addition, treating blood sugar to very low levels in older adults with drugs like insulin or sulfonylureas puts older patients at risk for dangerous low blood sugar events. 

But doctors and patients resist change in blood sugar interventions. "We have taught patients to strive to control their blood sugar, even when it gets to a point when it's safer to have 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 are testing whether similar approaches can be used to improve the quality of care in other areas where treatments may be overused such as opioids, sleeping pills and drug combinations that may cause harm. 

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 Care Overuse in Older Patients Using Professional Norms and Accountability."

The research was supported by National Institute on Aging of the National Institutes of Health award R33AG057383.