Choose Wisely Campaign

How would you like to undergo a blood test or have your child undergo a blood test only to discover that the test is of no clinical value in the day to day diagnosis and management of a medical condition? What if that test gave a result that was contrary to your own observations or that the test gave a positive response to something for which there was never an exposure? What about other treatments and diagnostics that are commonly done? What is their worth?

Readers of this website are well aware of my stand on certain aspects of allergy testing and other diagnostic tests done in the pursuit of allergy. Recently, a number of specialty organizations published their perspectives on ‘Unnecessary Medical Testing’. There continues to be activity about making patients and healthcare providers aware of the value of tests. This is particularly evident in the practice of allergy. Some of the tests that are offered are of no value and some of the offered tests do too much and are done outside the context of the basic mode of proper evaluation. Allergy is still one of those specialties in which we actually have to talk to families and children. We have to get a relevant history of symptoms and exposures to decide what tests need to be done. It is not a technology driven specialty- it is more people focused, history focused. The value of the test depends on the story that supports it.

There is a calling for LOUDER voices to help get the word out on this topic. Unnecessary testing wastes time, wastes money, and causes significant grief. Patients are put on the wrong pathway to the wrong goal. It is also possible that the result and recommendation based on that result may even be detrimental to someone’s health. Clearly, over-diagnosing allergy or making the wrong diagnosis can have an impact on the quality of a child’s and a family’s life.

The internet is replete with unsanctioned and unproven statements about these allergy tests. These sites have all the glitter and gold as well as testimony about their results. How can a family know what is valid? What is real and what may be ‘Snake Oil’? How can someone who is not savvy with medicine, diagnostics, and the nuances of allergy sort through the morass of opportunities out there that claim to diagnosis and treat an allergy?

One way to start is to see what the experts have to say about these offerings. That term may need defining. What is and who would be an ‘expert’.

Looking at this from the pediatric perspective, I would begin with a health care provider who knows and who has had training in pediatrics-you just have to know kids. Add to this someone who is a board certified allergist/clinical immunologist. The list of credentials may also include experience and perhaps publications- contributions to the literature on the topic of interest. The experts need to be objective and to share information that is to the point and understandable for families. We need to help families and healthcare providers make the correct decisions about diagnostics in the world of allergy.

When looking at something be critical- you are spending your dollar- spend it wisely. It is okay to ask;

  • Who is writing/advocating this?
  • What are their credentials?
  • Are they trained in allergy?
  • Are they board certified in allergy?
  • What kind of results do they have- that one is tough to sort out.

You may find that those who advocate tests are trained in laboratory science- not clinical medicine (seeing children and learning about their issues).

You may see that the training is more surgical versus medical- there can be a significant difference in perspectives depending on the individual.

I often get the response that insurance pays for the tests-followed by ‘who cares about the cost’. Sometimes insurance companies will cover costs, but what if they do not- who pay the bill? The blood test panel can cost in excess of $2000.

Now to the point (finally!)- This came from ENT Today, June 2012 and was written by Mary Beth Nierengarten. A previous post has mentioned things that should be questioned.

The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) are working together in the “Choosing Wisely” campaign to encourage healthcare providers to ‘provide the best patient care through the development of evidence-based guidelines as well as identify tools, services, and processes that lead to safe care within the specialty’.

AAAAI Recommendations

The American Academy of Allergy, Asthma and Immunology (AAAAI) was among the specialty societies that initially submitted a list of five tests or procedures identified as potentially unnecessary or overused. It recommends: (statements in italics are my thoughts)

  • Don’t perform unproven diagnostic tests, such as immunoglobulin G testing or an indiscriminate battery of immunoglobulin E tests, in the evaluation of allergy.

The above statement really needs to be emphasized. This is one of the most common reasons for calls and visits- revisiting these types of studies/allergy evaluations and trying to get things right for the child.

  • Don’t order sinus computed tomography or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

The key word here is acute. Acute means either rapid in onset or of short duration.

  • Don’t routinely perform diagnostic testing in patients with chronic urticaria.

Everybody worries about chronic (of long standing duration) hives. Almost every test known to medicine has been done to evaluate hives.

  • Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.

Intravenous gammaglobulin is antibody replacement for an antibody deficiency condition. Thank you Dr. Buckley- you trained me well.

  • Don’t diagnose or manage asthma without spirometry.

Spirometry measures airflow. Asthma is a disease of airflow obstruction. Use the correct tool to measure the problem- akin to managing hypertension without a blood pressure cuff.

The article is very interesting. The point is made that this campaign should go further forward to emphasize the harm of doing the unnecessary.

This says it best regarding food allergy panel (battery) testing, thank you Dr. Cox-

Dr. Cox said most of the five items listed by the AAAAI may be better directed at primary care physicians and other physicians who see patients on the front lines of health care. She noted the first item on the list in saying, “We [allergists] see a lot of patients coming to us with a battery of tests that might not have been directed by clinical history,” she said. “That becomes a problem with food testing because the patients come in and you’ll have a battery of positive food tests that aren’t clinically relevant to the patient.”

I obviously think that this effort, this campaign is long over-due. I wholeheartedly support it and I will be active in getting the work out- ‘Choose Wisely’ please.

Medicine changes, new things are out there, old things undergo scrutiny, one thing to be sure of is that there is always change. Questions are being asked- does this work? Why do we do it this way? What exactly does that test tell us? What is the rate of return for a test or procedure.

Because things change, we need to be at pace with what is valid, what is good, and what may not work anymore.

FEL (7-17-2012)

July 17, 2012 · fleickly · No Comments
Tags: , , ,  · Posted in: Allergies, Allergy Testing, Choosing wisely, Interesting articles, Questioning tests and procedures