Choosing Wisely: Part 1

I have read that health care costs are rising too fast and that it’s partly due to patients and doctors doing too many tests.  Are doctors doing anything to reduce this rise? [Part I]

Americans spend more on health care than any other country, but unfortunately our overall quality of care isn’t as good as many other Western countries.  In an attempt to improve this, doctors have initiated the Choosing Wisely campaign:  every physician organization is asked to identify which tests and procedures are more often harmful or inappropriate, rather than beneficial, and help their patients avoid these.
Both the American Geriatrics Society (AGS) and the American Academy of Hospice & Palliative Medicine (AAHPM) have made several recommendations, which I’ll discuss below.  

Item 1:  Don’t recommend feeding tubes in patients with advanced dementia; instead offer assisted feeding.
Careful hand-feeding is as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status, and patient comfort. Tube-feeding is associated with more agitation, increased physical and chemical restraints, and worsening pressure ulcers.

Item 2: Don’t use antipsychotics as first choice to treat behaviors of dementia.
People with advanced dementia are often agitated and resist care.  Using antipsychotic medicines (such as risperidone [Risperdal], quetiapine [Seroquel], haloperidol [Haldol]) routinely, can cause serious harm, including stroke and premature death; they should be used only if non-drug measures have failed and patients are a threat to themselves or others.

Item 3: Avoid low average blood sugars in most seniors; moderate control is generally better.
There is no evidence that strict control of blood sugar in older diabetics is beneficial.  Average blood sugars should be between 154 and 211 (equal to a blood A1C of 7% to 9% — diabetics should have this A1C done at least every 6 mo.), depending on one’s other health problems and life expectancy. 

Next time:  three more tests/procedures to avoid.