“It’s difficult because you want to do what’s best for your patient, and you want the patient to trust you. But at times patients will demand a test that you believe to be unnecessary. It definitely poses a conflict,” said Kristin Sokol, MD, Clinical Instructor in the Division of Allergy and Inflammation at Beth Israel Deaconess Medical Center in Boston.
Dr. Sokol was recently recognized by the American Academy of Allergy Asthma and Immunology (AAAAI) as a Choosing Wisely Champion for her work in advancing the campaign and reducing overuse in health care. Announced earlier this year, the Champions program is an initiative to recognize clinicians who are leading efforts to reduce overuse and waste in medicine. More than a dozen leading medical specialty societies have committed to participate in the program.
Improving care for patients with asthma
Dr. Sokol first explored the balance of maintaining patient trust while doing no harm during her time at the University of Texas Medical Branch (UTMB), where she trained under renowned ethicist Howard Brody, MD, whose 2010 New England Journal of Medicine article called for specialty societies to develop lists of overused or unnecessary tests and treatments and inspired creation of the Choosing Wisely campaign.
AAAAI had already published its first set of five Choosing Wisely recommendations while Dr. Sokol was in training, which included: “Don’t diagnose or manage asthma without spirometry.”
“I thought about my background in public health and bioethics, and how I could integrate those concepts into my work in allergy and immunology,” she said.
Current guidelines highlight the importance of a detailed patient history in addition to spirometry in the diagnosis and management of asthma. Dr. Sokol observed a prevalence of adults and children at UTMB being diagnosed with asthma without spirometry. A review of a large commercial insurance database confirmed that during a 10-year period, 134,208 patients were diagnosed with asthma, but only 47.6 percent had received spirometry in the year before or after diagnosis. Among the patients diagnosed with asthma without spirometry, nearly 80 percent received inhaler therapy.
“Many patients referred to me for asthma were on long-term preventive asthma medications without ever having spirometry performed,” she said. “When I asked patients if they ever had a breathing test done they would say, ‘no’ and that they have never even heard of one. They were just told they had asthma, with some patients having been on medications for years.”
In addition to the potential adverse health effects of taking unnecessary asthma medications, there is an unnecessary cost to society and patients as well – asthma medication can cost $200–$300 a month, compared to about $40 for an in-office spirometry.
“When used in the diagnosis and management of asthma at the appropriate and recommended times, in conjunction with a complete history and physical examination, spirometry use should prevent needless expense,” she said.
Dr. Sokol is testing an intervention to aid clinicians in avoiding overdiagnosis of asthma without spirometry, which she said is also a problem at Beth Israel where she currently practices. For example, she cites an asthma patient she recently saw who was on the same dose of inhaled steroid medication for 40 years despite not recalling ever having spirometry done.
Dr. Sokol is working with a resident to place an advisory in every asthma patient’s Online Medical Record (OMR) across the Beth Israel system. Physicians will receive an alert each time they see a patient with asthma that prompts them to check when they last had spirometry and ask the patient if their symptoms are well controlled.
Launching next year, Dr. Sokol has examined pre-test data in the OMR and found only 30 to 40 percent of asthma patients have had spirometry performed at Beth Israel.
Dr. Sokol says there are a several factors that have been noted as barriers to spirometry use, including not owning a spirometer, lack of time and office resources, lack of adequate training in performing and interpreting the test, lack of comfort in conducting the test, and the belief that spirometry may not provide data necessary for accurate diagnosis.
“This is a difficult problem to fix,” she said. “But if we could just get one staff member in each outpatient office who is trained in spirometry, and perhaps have it available just one day a week for patients, it would be incredibly helpful. Also, referring patients who have difficult-to-treat asthma to an allergist to have a complete evaluation including spirometry if the primary care provider does not have access to spirometry can help.”
Reducing overtesting for food allergies
In addition to her work to reduce the number of patients diagnosed with asthma without spirometry, Dr. Sokol is also addressing overdiagnosis related to food allergies. AAAAI’s list of Choosing Wisely recommendations states “Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy.”
“Overtesting, or testing that is not guided by history, is still seen in the allergy world,” she said. “The testing is not just costly, but an overdiagnosis can lead to unnecessary patient fear, food avoidance and lifestyle modifications. It can really negatively impact their quality of life.”
Dr. Sokol explains to her patients that many times what they believe is a food allergy may actually be something else—such as a food intolerance or an adverse food reaction—and that specific IgE testing for food allergy often does not need to be performed. Despite these assurances, she notes patients still request food allergy testing.
“Choosing Wisely can help clinicians and patients make better health care choices by encouraging conversations about the tests and treatments specialty societies like the American Academy of Allergy, Asthma and Immunology say may be overused or unnecessary. These conversations are an important starting point, but the real challenge is how to best implement Choosing Wisely in practice,” she said.
While Dr. Sokol acknowledges there are a number of barriers to fully realizing the goals of Choosing Wisely, she believes the next generation of clinicians may be able to fulfill this commitment – but only if they receive the proper training and guidance from those currently in practice.
“Choosing Wisely has an enormous potential to make changes in the health care system. Understanding how and why to avoid wasteful and unnecessary tests, treatments and procedures really needs to start in medical school, where we’re almost taught to do more,” she said. “It’s ingrained in us in the beginning of our careers. But I think we can make small changes that can make a big impact. Find out what is being done at your institution and seek to change it if there are unnecessary tests or procedures being performed. Talk to colleagues in other fields about the Choosing Wisely list in our specialty. Initiate conversations with medical students, residents and fellows. If we can get them early, I think we can make a change.”