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AANS Neurosurgeon : Patient Safety

Volume 24, Number 2, 2015

Screening Guidelines in Neurosurgery: Patient Safety First

Tyler Schmidt, DO; and Kristopher T. Kimmell, MD

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Screening Guidelines

Health-care reform has dominated the news over the past several years. Dire projections of escalating costs of health care have led to increased scrutiny for health-care providers. A frequent criticism of U.S. health care is that many tests and procedures are duplicative and frequently un-indicated. In particular, screening diagnostic tests to rule out diagnoses are widely felt to be over-utilized. There are a number of valid arguments on each side of this argument. For patients with a positive screening test that led to early diagnosis and treatment, such screening tests are life-saving. For patients with a false positive test who undergo further testing, the screening test exposed them to unnecessary potential risk. Many physicians would offer that they are compelled, by patient preference or medical-legal concerns, to order tests in situations where there is not good evidence for their use.

Efforts to Limit Unnecessary Tests
Despite these concerns, organized medicine has joined in national efforts to reduce health-care spending. One such effort is the Choosing Wisely initiative. First put forth by the American Board of Internal Medicine, the Choosing Wisely campaign now encompasses recommendations from many national physician organizations. The stated goal of Choosing Wisely is “to promote conversations between providers and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, truly necessary.” Additionally, the effort hopes to limit unnecessary tests, procedures or health-care practices. The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) contributed five recommendations to the Choosing Wisely campaign in 2014.

Critics of the Choosing Wisely guidelines point out that many recommendations are not validated by randomized controlled trials. Another concern is that application of such broad guidelines may imperil independent decision-making by physicians in situations of clinical uncertainty. Furthermore, contradictory guidelines exist from different national organizations. These issues should alert neurosurgeons that indiscriminately applying the Choosing Wisely guidelines to individual patients may not be in their best interests and may compromise patient safety.

Do Those Efforts Compromise Patient Safety?
For example, the American College of Radiology, American Academy of Neurology, Consumer Reports and The American Headache Society through Choosing Wisely recently discouraged neuroimaging for patients with uncomplicated stable headaches that meet criteria for migraine or do not display localizing symptoms or signs. (2-5) These recommendations are inconsistent with the experience of many neurosurgeons in clinical practice, in particular, those who treat brain tumors. A recent article in Neurosurgery put these recommendations to the test. The article points out that, based on a retrospective review of data from one institution, the Choosing Wisely neuroimaging recommendations would have failed to diagnose 3 percent to 7 percent of patients with brain tumors. (6) In addition, in this series, 24.2 percent of brain tumor patients presented with isolated headaches, no symptoms, or nonspecific symptoms. (6) This rate of false negatives, based on these recommended guidelines, represents a potential pitfall in patient safety. Early diagnosis of brain tumors is critical as it allows for prompt treatment, increased treatment options and better baseline performance, all which have been shown to translate to improved outcomes. Screening neuroimaging for brain tumors is typically an MRI that does not result in exposure to ionizing radiation, has a high sensitivity and specificity, and has minimal risk to the patient. In this case, an effort to decrease diagnostic imaging by Choosing Wisely may have the unintended consequence of delayed diagnoses and poorer outcomes.

By contrast, the AANS and CNS recently recommended not routinely screening for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage (SAH) or genetic disorders that may predispose to aneurysm formation. (7) This recommendation is based on the low rate of aneurysm rupture (for aneurysms <10 mm a rate of rupture of 0.05% per year). Screening for unruptured intracranial aneurysm frequently involves a CT angiogram or diagnostic catheter angiogram. Both these modalities expose the patient to ionizing radiation. Diagnostic angiogram carries a 1- to 3-percent stroke risk. (8) These imaging studies clearly confer greater risk to the patients.

In the coming years, the conflict of interest between population management medicine and patient-centered medicine will require vigilance on the part of national organizations, as well as individual clinicians to ensure the cornerstone for validating clinical guidelines, such as the Choosing Wisely campaign, strikes a balance between sensible clinical judgement and detailed research. In situations of diagnostic uncertainty, guidelines can never replace clinical judgment. Efforts to reduce cost in health care should not come at the expense of patient safety.

Tyler Schmidt, DO, is a junior neurosurgery resident at the University of Rochester Medical Center, Rochester, N.Y. Kristopher Kimmell, MD, is a senior neurosurgery resident at the University of Rochester Medical Center. A past Socioeconomic Resident Fellow of the Council for State Neurosurgical Society (CSNS), he serves on the AANS Neurosurgeon editorial board. The authors reported no conflicts for disclosure.

References

1. Burke JF, Skolarus LE, Callaghan BC, Kerber KA. Choosing Wisely: highest-cost tests in outpatient neurology. Ann Neurol. 2013;73(5):679-683.

2. Loder E, Weizenbaum E, et al: Choosing Wisely in Headache Medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

3. American College of Radiology. Choosing Wisely: Five Things Patients and Physicians Should Question. Accessed March 29, 2015.

4. Consumer Reports and ABIM Foundation. Choosing wisely: imaging tests for headaches. Accessed March 29, 2015.

5. Frishberg B, Rosenberg J, Matchar D, et al.; American Academy of Neurology: US Headache Consortium. Evidence-Based Guidelines in the Primary Care Setting: Neuroimaging in Patients with Nonacute Headache. Available at: Accessed March 29, 2015.

6. Dacey RG, Chicoine MR, Hawasli AH, Choosing Wisely: A Neurosurgical Perspective on Neuroimaging for Headaches. Neurosurgery. 2015;76(1):1-6.

7. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation 2000, 102 (18): 2300–8.

8. Hankey GJ, Warlow CP, Sellar RJ. Cerebral angiographic risk in mild cerebrovascular disease. Stroke. 1990;21:209-222.


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