Struggling to Reduce Unnecessary Tests and Treatments in Older Patients

Addressing the issue of overtesting and overtreatment in geriatric patients requires ongoing efforts, according to a recent study published in Annals of Internal Medicine.

Research Findings

The study, conducted in 60 primary care practices in Chicago, aimed to reduce unnecessary medical procedures through targeted interventions. Key areas of focus included urinalysis for women, PSA screening for men over 76, and medication management for diabetics.

Christine Liu, MD, of Stanford Medicine, commented that, “Behavior change takes multiple interventions and systemic changes.” The study revealed that initial interventions led to reductions in some tests but these changes were not sustained over time.

Intervention Details

In the study, clinicians in the intervention group received electronic health record prompts when attempting to order screens or prescriptions for targeted areas. They had to document a reason for bypassing alerts, ensuring justification for their decisions.

Stephen Persell, MD, the lead author, stated, “These alerts remind us that there is potential harm and prompt us to think before proceeding.” He highlighted that PSA screening and aggressive diabetes management can pose significant risks, such as rectal bleeding and heart attack, respectively, in the elderly population.

Sustained Reductions in Urinalysis

One success of the intervention was a sustained reduction in unnecessary urinalysis tests for women older than 65 without symptoms of a UTI, which can lead to antibiotic misuse and complications.

Challenges in Reducing PSA and Diabetes Interventions

PSA screening rates among men over 76 initially decreased from 31.6% to 21.8%, but rebounded to 26.2% after alerts stopped. For diabetes management, the initial reduction from 15.6% to 14.2% also dissipated over time.

Persell noted that PSA screening persists due to patient fear and misunderstanding about the nature of prostate cancer. Similarly, Liu emphasized that timelines and patient requests make it challenging for doctors to avoid overtreatment.

Why Ongoing Interventions Are Required

Ian Neel, MD, from UC San Diego Health, argued that constant alerts are necessary due to the complexity of a physician’s workload. He suggested that clinicians often lack specialized training to manage geriatric needs.

Neel proposed that continuous interventions help prevent reliance on memory alone, which is crucial for adherence to guidelines.

Conclusion

While the study highlights progress, it underscores the necessity for persistent educational intervention and systemic support to mitigate overtesting and overtreatment in geriatric care. This involves continuous reinforcement of best practices, addressing patient fears, and ensuring that doctors are adequately equipped to handle the complex needs of elderly patients.

This study was funded by the National Institute on Aging. Drs. Persell, Liu, and Neel reported no conflicts of interest.

Brittany Vargas is a medicine, mental health, and wellness journalist.

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