Darilyn V. Moyer

Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.

Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians.

BACKGROUND Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies. METHODS Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults. RESULTS Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise. HIGH-VALUE CARE ADVICE Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

SOLITARY THYROID NODULES : SEPARATING BENIGN FROM MALIGNANT CONDITIONS

Preview Diagnostic evaluation of a thyroid nodule is an important undertaking but need not be complex. Often, physicians can rapidly categorize a nodule as benign or malignant with reasonable accuracy through history taking, physical examination, laboratory studies, and diagnostic imaging. Results of fine-needle aspiration biopsy can then guide further steps in diagnosis and treatment. The authors describe key elements in the evaluation process.

Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians

In this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians examine the state of graduate medical education (GME) financing in the United States and recent proposals to reform GME funding. They make a series of recommendations to reform the current funding system to better align GME with the needs of the nations health care workforce. These recommendations include using Medicare GME funds to meet policy goals and to ensure an adequate supply of physicians, a proper specialty mix, and appropriate training sites; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per-resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles.

Maintenance of Certification

IN RESPONSE: These thoughts are important and reinforce the idea that the objections to the current MOC processes are not rejections of ongoing education or professional development. As we read these comments, it is clear that internists want to maintain competency and expand knowledge for the sake of their profession and the welfare of patients. We want processes that help us grow at many levels. Many internists believe that alternate strategies would help them succeed in this effort. Dr. Kelley challenges the MOC process to be more like FOAMed in ED medicine. He raises an important concern about continuing education. We can imagine changes in MOC that would enhance the enjoyment of learning. We hope that the ABIM Assessment 2020 project (1) will help transform MOC from merely a summative examination to a formative process (that is, a process that focuses on improving knowledge rather than one that only evaluates it). Dr. Ringel has concerns about the relevance of MOC to physicians with lifetime certificates. He makes explicit what many older physicians are doing in their engagement of MOC. We understand his concern. We who hold lifetime certificates are encouraged but not required to participate in MOC for certification. Dr. Ringel expresses uncertainty about the value of the MOC process as he nears retirement. We believe that a more formative process would help him feel engaged. Dr. Trainor raises a critical concern: differing initial MOC pass rates across specialty boards. We have cited this issue repeatedly and hope that the ABIM will respond. We agree that the progressively lower initial pass rate for the secure internal medicine board examination continues to be an unavoidable problem that needs to be addressed. Dr. Copeland speaks with wisdom as a former ACP and ABIM leader. We respect his opinions. Dr. Johnson asks how MOC is helping our patients. In the current climate that asks physicians to base decisions on the best evidence available, what evidence exists that the MOC process helps patients? Anecdotal and subjective validity will not suffice in the modern era. Dr. Spevetz worries that the internal medicine community is rebelling against the ABIM. This may be true. Internists opine about the problems of electronic health records, prior authorization, the current payment structure, and other administrative burdens that distract from patient care and practice enjoyment. The concern about MOC is not about goals but rather processes. We agree with the intent of requiring physicians to maintain competence in their profession but have questions about the current recertification examination and other aspects of MOC that are logistically burdensome for practicing internists with no evidence showing that patient care will be improved. The ABIM is now listening to our concerns and making changes that will hopefully encourage acceptance by internists and allow MOC to achieve its patient-centered goals. We thank all who have commented for reconfirming the importance of lifelong learning and maintaining professional competence while also asking legitimate questions about how best to reach these goals. We believe that the ABIM is now working to improve its MOC processes and applaud the strides that it has made. We look forward to continued joint efforts with the ABIM to foster ongoing improvements in MOC.