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Point and Counterpoint |

POINT: Are There Cases in Which Physicians Should Deviate From Recommendations Not to Order a Chest CT Scan? YesDeviation From Recommendations on CT Scan? Yes FREE TO VIEW

Scott D. Halpern, MD, PhD
Author and Funding Information

From the Departments of Medicine (Division of Pulmonary and Critical Care Medicine), Biostatistics and Epidemiology, and Medical Ethics and Health Policy, Leonard Davis Institute Center for Health Incentives and Behavioral Economics, Perelman School of Medicine at the University of Pennsylvania.

CORRESPONDENCE TO: Scott D. Halpern, MD, PhD, University of Pennsylvania, 719 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021; e-mail: shalpern@exchange.upenn.edu


FUNDING/SUPPORT: This work was supported by a Greenwall Foundation Faculty Scholar Award in Bioethics and by a fellowship from the American Board of Internal Medicine Foundation.

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following conflicts of interest: Dr Halpern reports an intellectual conflict of interest related to his service as co-chair of the American College of Chest Physicians (CHEST) and American Thoracic Society Choosing Wisely Task Force in Pulmonary Medicine. He reports no financial conflicts of interest related to this manuscript.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):1145-1147. doi:10.1378/chest.14-1585
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Published online

This case asks how a physician should respond to a 54-year-old former smoker (25 pack-years, quit 10 years ago) who returns to see the physician, requesting a low-dose chest CT scan to screen for lung cancer. “Doc, I know it is outside the guidelines. But I am worrying all the time that the residual scar from my pneumonia last year might be a lung cancer. And I am willing to pay cash for the study.” We are specifically asked to consider whether the physician should order the chest CT scan with the diagnosis “abnormal chest radiograph, [International Classification of Diseases, Ninth Revision] ICD-9 793.2.”

There are at least three interesting elements to this case. First, might it be appropriate to order a chest CT scan for a patient who does not meet published guidelines for CT scan-based lung cancer screening? Second, of what relevance is the patient’s willingness to pay for the test? Third, is it appropriate for the physician to support the patient by entering an indication (abnormal chest radiograph) that may be seen as skirting the true reason for the test, which is to screen for lung cancer. I will focus my comments on the first of these important questions, while touching briefly on the second. I will take the liberty of assuming that the patient would not be worried about lung cancer, and, hence, would not have requested the CT scan, had it not been for the abnormal chest radiograph, thereby making the question of the coding somewhat less contentious.

To begin, it is easy to see that this patient does not quite meet the published guidelines for CT scan-based lung cancer screening.1-4 He was a year too young and smoked 5 pack-years “too few” (if one can say that) to have been included in the National Lung Screening Trial. Moreover, evidence suggests that only the highest-risk patients within that trial’s eligibility criteria benefited from screening,5 a group with risks clearly different from those of this patient. The patient not only falls outside the published criteria for whom to screen, but also meets the criteria for those whom physicians are now explicitly advised not to screen. The Top 5 list in Pulmonary Medicine, recently published as part of the Choosing Wisely Campaign with endorsements from the American College of Chest Physicians (CHEST) and the American Thoracic Society, actively suggests that physicians not order screening chest CT scans for patients at a low risk of lung cancer.6,7 Thus, the case poses an important dilemma for physicians: Should diagnostic tests or other medical services for which the overall benefits are small, particularly in relation to the services’ costs, ever be ordered for individual patients? In other words, should the ordering of “low-value” services be “never events?”

The importance of this question stems from the fact that physicians are major drivers of the skyrocketing health-care costs in the United States. As Brody8 noted, “the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained.” Thus, physicians have core professional responsibilities for adhering to guidelines that are designed, in large part, to limit costs and increase the overall value of health care.9 However, because it is only possible to define low-value care among populations of patients, the critical goal of practicing cost-conscious medicine need not require eliminating such services altogether, but rather dramatically reducing their current overuse.

It is at least conceivable that the patient in this case would be a legitimate outlier for whom ordering the CT scan would not be “low-value.” For example, the patient’s willingness to pay for the CT scan is relevant insofar as it may reflect the degree to which the patient’s fear is leading to a reduced quality of life. If the patient’s general well-being was substantially reduced by worry, be it rational or irrational, this could make the CT scan far more cost effective for this particular patient than for patients overall (eg, through reductions in downstream use of resources to help alleviate anxiety and stress). Importantly, this is not an argument that health-care services ought to be allocated according to the ability or willingness of patients to pay. I do not even advocate routine inquiries regarding whether patients would be willing to pay for services as a means of determining how important the service is to patients. However, physicians are practicing good medicine when they consider the unique elements of a case and consider whether there exist objective reasons to think that a particular patient differs from those in whom the service is known to be of low value. Policies that allow for such individualized care, while also strongly encouraging major reductions in use for the far more common cases that better align with the guidelines, are similarly responsible. But to be effective and defensible, policies that would monitor physicians’ use rates (and potentially reimburse accordingly) must be carried out at the physician, or even practice, level, not at the level of individual patients.

Patient-level policies would only be defensible if we could directly measure all the potential nuances related to an individual circumstance, and thereby say with confidence that the service is low value for that specific patient. Using such carefully selected and well-characterized patients as the denominator, the appropriate service use rate would indeed be 0%.10 However, because of the difficulties of the measurement task, very few direct measures exist. By contrast, indirect measures use coarser population-level data to identify patients for whom the benefits of a service are, on average, either outweighed by the harms or insufficient in relation to the costs. The appropriate use rate for such measures is low but is not necessarily 0%. The cruder our ability to distinguish patients who will and will not benefit appreciably from a service, the more tolerant we must be of service provision rates that slightly exceed 0%.11

This is analogous to considering what the optimal rates are for reintubation, ICU readmission, or surgical removal of nonruptured appendixes. As a society, we want the rates for each of these events to be low. However, to drive these rates close to 0% would require keeping most patients intubated for too long, extending their ICU stays beyond the points at which value is being added, or failing to remove some appendixes that truly need to come out. In each of these cases, actions driven by the laudable goal of frugality would have instead yielded higher costs and direct patient harm.

The goal of driving use rates down without striving to make them never events in no way contravenes the goals of the Choosing Wisely campaign or other initiatives to reduce low-value care. Indeed, for many of the Choosing Wisely items studied to date, baseline rates of overuse are very high,12 suggesting considerable opportunity for reining in health-care costs without driving them down to 0%. The virtue of each item on a Choosing Wisely list is not that it represents the best care for every potential patient. Rather, it is that each of the > 300 items across > 60 lists represents a physician-led, professional-society-endorsed promotion of the social goal of cost-conscious medical practice. Thus, the most important legacy of initiatives such as the Choosing Wisely campaign may well be to direct the core ethics and behavior of medical professionals away from the antiquated ethic (still endorsed by the American Medical Association13) of doing everything for the patient in front of you. Over time, and by incorporating cost-conscious practice into medical education,14 these national initiatives may help move us toward a more defensible ethic of balancing our undeniable duties to individual patients with our equally compelling duties to all potential patients (ie, society writ large). Such progress would be sustainable and self-reinforcing, rather than the unstable and potentially self-defeating advances that would come by requiring 100% adherence to “don’t do” lists.

In summary, physicians should routinely abstain from ordering chest CT scans to screen for lung cancer for patients who are not at a high risk based on published guidelines. Broad adherence to such carefully considered recommendations promotes the dual duties of physicians to their own patients and to society at large. However, for the small number of patients who are not at a high risk based on conventional criteria, but for whom there are objective and defensible reasons that a chest CT scan may be high value, deviating from this routine therapeutic paradigm may be warranted. It is not clear that the patient presented in the current case possesses sufficiently unique circumstances to warrant a departure from routine care. However, before making this determination, responsible physicians would further explore the extenuating circumstances that may exist and consider the possibility that this patient is sufficiently different from those about whom we have reliable evidence that ordering a chest CT scan is justified.

Role of sponsors: The sponsors had no role in determining the content of this manuscript or in the decision to submit it for publication.

LDCT

low-dose CT

NLST

National Lung Screening Trial

USPSTF

US Preventive Services Task Force

Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):7S-37S. [CrossRef] [PubMed]
 
Humphrey LL, Deffebach M, Pappas M, et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013;159(6):411-420. [CrossRef] [PubMed]
 
Kovalchik SA, Tammemagi M, Berg CD, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med. 2013;369(3):245-254. [CrossRef] [PubMed]
 
American College of Chest Physicians and American Thoracic Society Choosing Wisely Task Force. Top 5 list in pulmonary medicine. The ABIM Foundation website. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/. Accessed March 17, 2014.
 
Wiener RS, Ouellette DR, Diamond E, et al; American Thoracic Society; American College of Chest Physicians. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest. 2014;145(6):1383-1391. [CrossRef] [PubMed]
 
Brody H. Medicine’s ethical responsibility for health care reform—the Top Five list. N Engl J Med. 2010;362(4):283-285. [CrossRef] [PubMed]
 
Sox HC, Blank L, Cohen J, et al; ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246. [CrossRef] [PubMed]
 
Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC; American College of Physicians Performance Measurement Committee. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-59. [CrossRef] [PubMed]
 
Gawande AA, Colla CH, Halpern SD, Landon BE. Avoiding low-value care. N Engl J Med. 2014;370(14):e21. [CrossRef] [PubMed]
 
Kale MS, Bishop TF, Federman AD, Keyhani S. “Top 5” lists top $5 billion. Arch Intern Med. 2011;171(20):1856-1858. [CrossRef] [PubMed]
 
American Medical Association. AMA code of medical ethics. AMA website. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion203page?. Accessed March 31, 2014.
 
Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386-388. [CrossRef] [PubMed]
 

Figures

Tables

References

Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
 
Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012;307(22):2418-2429. [CrossRef] [PubMed]
 
Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):7S-37S. [CrossRef] [PubMed]
 
Humphrey LL, Deffebach M, Pappas M, et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013;159(6):411-420. [CrossRef] [PubMed]
 
Kovalchik SA, Tammemagi M, Berg CD, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med. 2013;369(3):245-254. [CrossRef] [PubMed]
 
American College of Chest Physicians and American Thoracic Society Choosing Wisely Task Force. Top 5 list in pulmonary medicine. The ABIM Foundation website. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/. Accessed March 17, 2014.
 
Wiener RS, Ouellette DR, Diamond E, et al; American Thoracic Society; American College of Chest Physicians. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest. 2014;145(6):1383-1391. [CrossRef] [PubMed]
 
Brody H. Medicine’s ethical responsibility for health care reform—the Top Five list. N Engl J Med. 2010;362(4):283-285. [CrossRef] [PubMed]
 
Sox HC, Blank L, Cohen J, et al; ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246. [CrossRef] [PubMed]
 
Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC; American College of Physicians Performance Measurement Committee. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-59. [CrossRef] [PubMed]
 
Gawande AA, Colla CH, Halpern SD, Landon BE. Avoiding low-value care. N Engl J Med. 2014;370(14):e21. [CrossRef] [PubMed]
 
Kale MS, Bishop TF, Federman AD, Keyhani S. “Top 5” lists top $5 billion. Arch Intern Med. 2011;171(20):1856-1858. [CrossRef] [PubMed]
 
American Medical Association. AMA code of medical ethics. AMA website. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion203page?. Accessed March 31, 2014.
 
Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386-388. [CrossRef] [PubMed]
 
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