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• Posted February 12, 2024

Doctor 'Alert' Warnings Helped One Health System Reduce Unnecessary Tests

The doctor tapped at his computer, ordering a routine prostate exam for an 80-year-old man, when a dramatic yellow alert popped up on the patient's electronic health record.

"You are ordering a test that no guideline recommends," it warned. "Screening with PSA can lead to harms from diagnostic and treatment procedures. If you proceed without a justification, the unnecessary test will be noted on the health record."

The message was part of a strategy Northwestern Medicine investigators were testing to see if it would prompt doctors to stop ordering unnecessary screenings for older adults.

And it worked, according to a new report in the Annals of Internal Medicine.

Researchers observed a significant 9% decrease in unnecessary PSA tests after 18 months of delivering the alerts, as well as a nearly 6% decrease in urine tests for urinary tract infection in women.

"To our knowledge, this is the first study to significantly reduce all of the unnecessary testing or treatments studied using point-of-care alerts,"said lead researcher Dr. Stephen Persell, a professor at Northwestern University Feinberg School of Medicine in Chicago.

This study involved 370 clinicians at 60 Northwestern Medicine clinics. Half received the alerts, and half did not.

Prior studies have attempted to reduce unnecessary screenings using messages delivered to doctors through electronic health records, but Persell and his team think they've hit upon the right combination of phrases to influence doctors.

"We believe that incorporating elements like a focus on potential harms, sharing social norms and promoting a sense of social accountability and reputational concerns led to the effectiveness of these messages,"Persell said in a university news release.

"If messages clinicians find compelling can be delivered by electronic health records at the time clinicians place their orders, this could be a straightforward way to improve care and could be applied across large health systems easily,"he added.

Screening men older than 75 for prostate cancer can lead to treatment that won't extend their lives, prior research has found. They're better off simply living with an indolent cancer of which they're unaware. (An indolent cancer is one that would not show symptoms in a patient's lifetime and would not contribute to death.)

The same is true of women 65 and older tested for urinary tract infections without any symptoms, and patients 75 and older with high blood sugar, researchers said.

"These are screening practices people have adopted without good evidence,"Persell said. "If a man is not going to live another 10 or 15 years due to his age, you won't save his life from prostate cancer by screening him, but you will subject him to the potential harms of treatment."

The patient could wind up undergoing surgery or radiation treatment that can cause urinary incontinence or urinary symptoms, impair sexual function or cause rectal bleeding, he noted.

"What's right for a 68-year-old man might not be right for one who is 75 or 85 years old,"Persell said.

The same is true for urinary tract infections in women 65 and older, Persell said. 

"These asymptomatic urinary tract infections are common in older women, but there is no evidence that you can improve a woman's health with antibiotics,"Persell said.

However, antibiotics can cause allergic reactions, diarrhea and antibiotic resistance, which could make bacterial infections harder to treat in the future, Persell said.

Treating blood sugar to very low levels in adults using drugs like insulin or sulfonylureas is also dangerous, as it increases their risk for hypoglycemia.

Unfortunately, the messages didn't work as well when it came to reining in unnecessary tests for blood sugar levels, either for doctors or patients.

"We have taught patients to strive to control their blood sugar, even when it gets to a point when it's safer to have slightly less controlled blood sugar,"Persell said. "It's hard to convince patients and doctors to change their goals."

Researchers next hope to try these messages to stem other types of overtreatment, including opioid and sleeping pill prescriptions and potentially dangerous drug combinations.

More information

The University of Colorado has more about overtreatment.

SOURCE: Northwestern University, news release, Feb. 6, 2024