An Official American Thoracic Society/American College of Chest Physicians Policy Statement

Abstract

CHEST T he United States spends more per capita on health care than any other developed nation. 1 Although spending more money yields health benefi ts in some contexts, the United States has crossed onto the "fl at of the curve," in which spending more does not improve health. 2 Research on geographic variations in healthcare spending has shown that spending more money, doing more testing, and providing more expensive treatments does not consistently yield better outcomes. 3 In fact, in many cases, overtesting and overtreatment can cause harm, as patients are exposed to radiation from extraneous imaging, physical complications from invasive procedures that are not clearly indicated, and adverse effects from unwarranted medications. 4 Physicians have professional obligations to both their individual patients and to society. 5 As such, it is incumbent upon physicians to help rein in the use of tests and treatments that offer little benefi t, may cause harm, and add considerable expense. The question is, where to begin? It can be diffi cult for busy clinicians to stay up-to-date on the latest evidence on the benefi ts and harms of all tests and treatments in their fi eld, and (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated-and when they are not.

Limited Hospital Variation in the Use and Yield of CT for Pulmonary Embolism in Patients Undergoing Total Hip or Total Knee Replacement Surgery

“…Before one performs CT, guidelines recommend the use of simple clinical prediction tools, such as the Wells score or the Geneva score, to avoid use of CT in patients for whom clinically important PE can be excluded (31,32). In our study, the overall mean positivity rate (12.3%) was slightly higher than that reported in previous studies in patients in the emergency department (1,5,(7)(8)(9); however, it was comparable to those in studies conducted in hospitalized patients (range, 12.0%-20.1% in the United States) (6,33). In New Zealand, a positivity rate of 19%-60% was reported among patients who had undergone CT PA after TKR or THR (34), and orthopedic surgeons had the highest CT PA yield among different referring physicians (35).…”

“…For the Choosing Wisely campaign, both the American College of Radiology and the American Thoracic Society and American College of Chest Physicians included the use of "chest CT angiography to evaluate possible PE in patients with a low clinical probability" as one of the top five procedures that physicians should question in clinical practice (5,29). These recommendations are primarily based on the increased total number of CT PA examinations performed over time (30) and the reported low positivity rate (1,5,(7)(8)(9). The symptoms of acute PE are often nonspecific, while the mortality rate is high, if PEs at hospitals in the other two groups (12.9% vs 11.3% and 11.9%, P = .37); however, the difference was not significant (Table 1).…”

“…T here is a growing body of evidence that improved access to computed tomographic (CT) imaging, high diagnostic accuracy, ability to detect ancillary findings or make an alternative diagnosis, and a recent trend for defensive medicine have lowered the threshold for performing CT pulmonary angiography (PA) to detect pulmonary embolism (PE) (1)(2)(3)(4). Overuse of CT PA is a concern in terms of contrast material-induced nephropathy and anaphylactoid reaction, radiationinduced cancer, and increased health care cost (5,6). Overuse of this technology has been discussed intensely based on low reported positivity rates (,10%) (1,5,7-9), but these data generally are derived from single-institution studies or from multicenter trials that include fewer than 10 institutions.…”

Clinically Meaningful Use of Blood Tumor Markers in Oncology

“…However, many intermediate size pulmonary nodules evade a clear diagnosis based on imaging alone and might be too small for CT-guided or transbronchial biopsy. These patients would currently be followed up with short-term imaging, which is costly and exposes them to additional radiation [32]. A panel of six TMs (CEA, cancer Antigen 15-3 [CA15-3], squamous cell carcinoma antigen [SCCA], cytokeratin 19 fragment [CYFRA 21-1], neuron-specific enolase [NSE], and ProGRP) was recently shown to be more accurate in predicting the presence of lung cancer than either a single TM alone or clinical factors such as tumor size and smoking status [33].…”

Extolling “palliative radiology” in the frail and elderly: each drop makes an ocean!

“…Furthermore, recently as part of the "Choosing Wisely" campaign, various professional societies in order to curtail healthcare costs and improve patient care have laid down their recommendations by identifying the "top five tests" or "treatments" in their speciality that are being used too frequently and/or inappropriately. 5,6 Following their footsteps, it would be worthwhile if radiological societies somewhere down the road can work towards establishing guidelines and drafting recommendations for "choosing wisely" in the geriatric population.…”