In recent years, the medical community has grappled with the issue of unnecessary tests and treatments, particularly for older adults. Despite efforts, clinicians continue to prescribe medications such as insulin or meglitinide to diabetic patients over 75 years old with A1c levels below 7%. This trend persists partly due to patient resistance to stopping medications they believe they need. The Choosing Wisely initiative, spanning 11 years until 2023, aimed to mitigate these unnecessary medical interventions. However, the challenge remains significant.
A notable example is the administration of PSA screens in men older than 76 years, which are often deemed unnecessary due to limited life expectancy and the typically slow-growing, asymptomatic nature of prostate cancer. A recent cluster trial conducted at 60 primary care practices in Chicago evaluated methods to reduce such tests. The study received funding from the National Institute on Aging.
The trial divided clinicians into two groups: an intervention group and a control group. The intervention group, comprising 184 clinicians, received electronic health record prompts when attempting to order certain screens or prescriptions. These alerts significantly reduced PSA screen rates, with the intervention group conducting 21.8% per 100 eligible patients compared to 31.6% in the control group.
"With these alerts, we're saying 'There is potential harm, and you should think about it before you do this,'" said Stephen Persell, MD.
However, the reduction in PSA screens was not sustained beyond the year-long trial. Many physicians bypassed warnings, often citing patient demand, previously elevated test results, or patient-reported requests from other clinicians as justifications.
The trial also highlighted the use of UTI screens. By the intervention's end, UTI screen rates were lower in the intervention group than in the control group (18.3% vs 23.1% per 100 patients). Yet, like with PSA screens, rates remained unchanged after the intervention period concluded.
"They added a couple of extra steps, but I don’t think that’s sufficient. Behavior change takes multiple interventions and also more of a systemic, wider change as well," remarked Christine Liu, MD.
Reducing unnecessary and potentially harmful tests and treatments for geriatric patients requires ongoing interventions. The risk of dangerous blood sugar drops increases for older adults on unnecessary diabetes medications. Physicians often lack training to understand and best treat geriatric patients, necessitating reminders to curb unnecessary tests and treatments.
"Physicians have so many things to keep track of and watch out for, trying to rely upon memory to adhere to it all is way too difficult to achieve," noted Ian Neel, MD.
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