5 Tips for Cutting Wasteful Spending in Neurology

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5 Tips for Cutting Wasteful Spending in Neurology
5 Tips for Cutting Wasteful Spending in Neurology

The United States has the most expensive yet least effective health care system, as compared with those of other nations. 1 According to the Institute of Medicine, some $750 billion was spent on "wasted medical services" in 2009 alone.2

If these expenditures continue unchecked, health care spending is projected to constitute a quarter of the gross domestic product by 2025.3 Rising health care costs—caused in part by "wasteful practices"—render millions of citizens vulnerable and have a deleterious impact on the nation's economy.1

To address wasteful practices, the American Board of Internal Medicine Foundation (ABIMF) initiated the "Choosing Wisely" campaign, which encouraged medical specialty societies to develop lists of the five procedures or examinations in their specialty that may contribute to health care waste, and are not supported by evidence of benefit and non-evidence of harm.4

The American Academy of Neurology (AAN) has published its own recommendations in an article titled, "The American Academy of Neurology's Top Five Choosing Wisely Recommendations."5 They emphasize that these recommendations are "not intended to eliminate use of these procedures or tests entirely, but rather to give patients and physicians full information to engage in an honest discussion about when and in whom these medications, tests, or procedures may be more harmful than beneficial, or simply unnecessary."5

Recommendation #1: Don't perform EEGs for headaches.

Headache is the "most common pain disorder," affecting 15 to 20 percent of people.5 According to a 1995 literature review,6 the electroencephalogram (EEG) has no advantage over clinical evaluation in diagnosing headaches. Moreover, patients with clinically diagnosed migraine have high-frequency photic driving responses (H responses) on EEG,6 but routine EEGs do not typically include the high frequencies necessary to identify an H response; and identifying an H response offers no advantage over clinical reference standards in diagnosing headache disorders. In cases in which structural abnormities are suspected, patients benefit more from higher-sensitive neuroimaging studies, such as CT or MRI.7

Recommendation #2: Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

The authors state that "occlusive carotid artery disease does not cause fainting, but rather causes focal neurologic deficits such as unilateral weakness." 5, 8 They add that fainting is extremely common, with a lifetime prevalence of 40 percent.9 They conclude EEG in patients with syncope is "wasteful" and may yield incidental findings that are irrelevant and lead to unnecessary and potentially harmful further testing. Additional sources for their recommendations are the AHA/ACCF Scientific Statement on the Evaluation of Syncope,10 and the NICE Guideline on transient loss of consciousness in adults and young people.11

Recommendation #3: Don't use opioids or butalbital for the treatment of migraine, except as a last resort.

Effective "migraine-specific medications" or nonopioid, nonbarbiturate analgesics should be used for treatment of migraine.7,12,13,14,15,16 Opioids and butalbital "increase medication overuse headache and chronic migraine."17 Opioids should be considered only as "rescue therapy" if migraine-specific treatments are infective or are contraindicated. In these circumstances, "use should be limited to nine days per month," and providers should "focus on preventive and behavioral aspects of migraine care."

Recommendation #4: Don't prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of multiple sclerosis (MS).

According to the authors,"“interferon-b and glatiramer acetate do not prevent the development of permanent disability in progressive forms of MS." Instead, they "increase costs and have frequent side effects that may adversely affect quality of life." These agents reduce relapse rates in patients with relapsing-remitting MS who have no significant disability at the time of treatment initiation.18,19,20 Moreover, interferon-b slows short-term, relapse-related disability progression in this population, but not in the case of established disability in primary or secondary progressive MS.21,22 The authors review side effects of both agents, adding that "prescribing these medications to patients with disability from progressive MS, who have not had recent relapses, increases cost without adding benefit, and frequently causes side effects that may adversely affect the patient's quality of life."

Recommendation #5: Don't recommend carotid endarterectomy (CEA) for symptomatic carotid stasis unless the complication rate is low (<3%).

Surgery to repair a narrowed carotid artery in asymptomatic patients "slightly" reduces stroke risk, but the benefits are seen only in situations with "documented combined surgical and angiographic complication of <3%"10,23,24,25,26 and (according to the American Heart Association) with >70% stenosis.27

Conclusion

The authors point out that "there are no studies that detail how much wasteful spending and patient harm can be prevented by following the Choosing Wisely recommendations." The AAN's goal is "to develop successful implementation strategies for its first Top Five list and to obtain accurate estimates of how much wasteful spending can be prevented if these or future recommendations are followed."

References

  1. Kumar S, Ghildayal NS, Shah RN. Examining quality and efficiency of the U.S. healthcare system. Int J Health Care Qual Assur. 2011;24(5):366-388.
  2. Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press: 2012. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2012/Best-Care/Best%20Care%20at%20Lower%20Cost_Recs.pdf. Accessed: April 7, 2013.
  3. Martin AB, Lassman D, Washington B, Catlin A; National Health Expenditure Accounts Team. Growth in US health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Aff (Millwood). 2012;31(1):208-219.
  4. American Board of Internal Medicine Foundation. Choosing wisely: an initiative of the ABIM Foundation. Available at: http://www.choosingwisely.org. Accessed: April 7, 2013.
  5. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology's Top Five Choosing Wisely recommendations. Neurology. February 20, 2013. [Epub ahead of print]
  6. Gronseth GS, Greenberg MK. The utility of the electroencephalogram in the evaluation of patients presenting with headache: a review of the literature. Neurology. 1995;45(7):1263-1267.
  7. Silberstein SD; US Headache Consortium. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754-762.
  8. Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS). Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30(21):2631-2671.
  9. Ganzeboom KS, Mairuhu G, Reitsma JB et al. Lifetime cumulative incidence of syncope in the general population: a study of 549 Dutch subjects aged 35-60 years. J Cardiovasc Electrophysiol. 2006;17(11):1172-1176.
  10. Brott TG, Halperin JL, Abbara S et al. 2011 ASA/ACCF/AHA/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation. 2011;124:e54-e130.
  11. National Institute for Health and Clinical Excellence. Transient loss of consciousness (‘blackouts') management in adults and young people. London: Royal College of Physicians (UK); 2010. Available at: publications.nice.org.uk/transient-loss-of-consciousness-blackouts-management-in-adults-and-young-people-cg109/notes-on-the-scope-of-the-guidance. Accessed: April 7, 2013.
  12. Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. Eur J Neurol. 2009 Sep;16(9):968-81.
  13. Institute for Clinical Systems Improvement. Headache, Diagnosis and Treatment of (Guideline). Bloomington, MN: Institute for Clinical Systems Improvement; 2011. 
  14. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Headache. 2012;52(1):114-128.
  15. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others. Headache. 2012;52(2):292-306.
  16. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications. Headache. 2012;52(3):467-482.
  17. Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine. Pain. 2009;142(3):179-182.
  18. Rice GPA, Incorvaia B, Munari LM et al. Interferon in relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev. 2001, Issue 4. Art. No.: CD002002. DOI: 10.1002/14651858.CD002002.
  19. La Mantia L, Munari LM, Lovati R. Glatiramer acetate for multiple sclerosis. Cochrane Database Syst Rev. 2010, Issue 5. Art. No.: CD004678. DOI:10.1002/14651858.CD004678.pub2.
  20. O'Connor P, Filippi M, Arnason B et al. 250 microg or 500 microg interferon beta-1b versus 20 mg glatiramer acetate in relapsing-remitting multiple sclerosis: a prospective, randomised, multicenter study. Lancet Neurol. 2009;8(10):889-897.
  21. La Mantia L, Vacchi L, Di Pietrantonj Cm et al. Interferon beta for secondary progressive multiple sclerosis. Cochrane Database Syst Rev. 2012, Issue 1. Art. No.: CD005181. DOI: 10.1002/14651858.CD005181.pub3.
  22. Rojas JI, Romano M, Ciapponi A et al. Interferon Beta for Primary Progressive Multiple Sclerosis. Cochrane Database Syst Rev. 2010, Issue 1. Art. No.: CD006643. DOI: 10.1002/14651858.CD006643.pub3.
  23. Chaturvedi S, Bruno A, Feasby T et al. Carotid endarterectomy: an evidence-based report of the Technology and Therapeutics Committee of the American Academy of Neurology. Neurology. 2005;65:794-801.
  24. Ricotta JJ, Aburahma A, Ascher E et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54(3)e1-31.
  25. Kresowik TF, Bratzler DW, Kresowik RA et al. Multistate improvement in process and outcomes of carotid endarterectomy. J Vasc Surg. 2004;39:372-380.
  26. Wolff, Guirguis-Blake J, Miller T et al. Screening For Asymptomatic Carotid Artery Stenosis. Rockville. MD: Agency for Health Care Quality (US), 2007 Dec. Appendix 4-Evidence Table on Complication Rates for Carotid Endarterectomy.
  27. Goldstein LB, Bushnell CD, Adams RJ et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011. 42(2):517-84.
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