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In a proactive effort to help stem healthcare spending, nine medical specialty organizations have published their top 5 lists of tests, treatments, or services that are unnecessary or at least should include a thorough conversation between patients and their doctors regarding the benefits and risks of before undertaking the procedure.

The lists are part of a campaign called Choosing Wisely, organized by the American Board of Internal Medicine Foundation. The medical societies, for example, advise against immediately prescribing antibiotics for sinusitis, ordering an MRI during the initial evaluation of back pain, and doing an exercise stress test for people who don鈥檛 have any signs or symptoms of heart disease. (See the top two 鈥渄ont鈥檚鈥� from each specialty below, or visit to see all 45.) Eight more medical specialty organizations are planning to join the campaign.

The purpose of making these lists, says the foundation, is to help doctors and their patients talk about tests and procedures in order to choose the ones that:

• are supported by evidence
• don鈥檛 duplicate other tests or procedures
• are free from harm
• are really needed

Spending healthcare dollars wisely

In a recent article in the , former Medicare administrator Dr. Donald Berwick and a colleague argue that as much as $900 billion dollars of health care spending is wasted each year. A big chunk of this comes from doctors ordering tests that yield little useful information or performing procedures that don鈥檛 make their patients better. This happens for several reasons. Some doctors just don鈥檛 know which procedures or tests are useful and which ones aren鈥檛. Some order useless tests because their patients expect or ask for them. Others do it to protect themselves from possible lawsuits.

Take the exercise stress test as an example. It involves walking on a treadmill while monitors record the heart rate, heart rhythm, and blood pressure. It鈥檚 a useful test for people who have symptoms that might indicate heart disease, like chest pain when they are active or under stress. But as with many tests, it isn鈥檛 useful just to 鈥渃heck under the hood鈥� in people who feel fine.

About 15% of the time, an exercise stress test suggests that there may be a heart problem, when in fact there isn鈥檛. These 鈥渇alse-positives鈥� can lead to needless worry and further testing, often including an invasive angiogram. To perform that test, a doctor must insert a thin wire and plastic tube called a catheter into a blood vessel in the groin and maneuver it into the heart. Angiogram-related complications aren鈥檛 rare.

And if the test shows a narrowing in an artery, many doctors and their patients are prone to fixing it with angioplasty and placement of a stent鈥攚hich also can have complications and long-lasting repercussions鈥攅ven though doing this won鈥檛 make the person feel better, protect him or her from having a heart attack, or live longer.

More isn鈥檛 better

Avoiding tests and procedures that aren鈥檛 effective or useful saves time and money, and protects the recipients from harm. For the Choosing Wisely campaign to be a success, all of us鈥攄octors and their patients alike鈥攎ust stop believing that if some medical care is good, more is better.

Top two 鈥渄on鈥檛s鈥� from 9 medical specialty organizations

American Academy of Allergy, Asthma & Immunology

• Don鈥檛 perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, when evaluating a possible allergy.
• For uncomplicated acute sinusitis, don鈥檛 order sinus computed tomography (CT) or indiscriminately prescribe antibiotics.

American Academy of Family Physicians

• Don鈥檛 do imaging for low back pain within the first six weeks, unless red flags are present.
• Don鈥檛 routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

American College of Cardiology

• When initially evaluating patients who are not having cardiac symptoms, don鈥檛 perform stress cardiac imaging or advanced non-invasive imaging unless there are markers the patient is at high risk.
• Don鈥檛 perform stress cardiac imaging or advanced non-invasive imaging as part of routine follow-ups in patients without symptoms of cardiovascular disease.

American College of Physicians

• Don鈥檛 perform exercise electrocardiogram testing (exercise stress test) in patients who do not have any symptoms of heart disease and who are at low risk for coronary heart disease.
• Don鈥檛 obtain imaging studies in patients with non-specific low back pain.

American College of Radiology

• Don鈥檛 do imaging for uncomplicated headache.
• Don鈥檛 image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

American Gastroenterological Association

• When prescribing long-term acid suppression therapy for gastroesophageal reflux disease (GERD), choose the lowest dose of a proton pump inhibitor or histamine2 receptor antagonist to achieve therapeutic goals.
• Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

American Society of Clinical Oncology

• Don鈥檛 use cancer-directed therapy for patients with a solid tumor who have the following characteristics: low performance status, no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.
• Don鈥檛 perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

American Society of Nephrology

• For patients on dialysis who have limited life expectancies, don鈥檛 perform routine cancer screening unless the patient has signs or symptoms of cancer.
• Don鈥檛 administer drugs that stimulate red blood cell production in patients with chronic kidney disease who do not have symptoms of anemia if their hemoglobin levels are greater than or equal to 10 g/dL.

American Society of Nuclear Cardiology

• Don鈥檛 perform stress cardiac imaging or coronary angiography in patients without signs or symptoms or cardiac disease unless they have other markers indicating they are at high risk for cardiac disease.
• Don鈥檛 perform cardiac imaging for patients who are at low risk.

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