Choosing Wisely

‘Choose Wisely’ is a project promoted by Consumer Reports and organized by the American Board of Internal Medicine (ABIM).  Its purpose?  To encourage doctors and patients to follow evidence-based guidelines as they manage health problems.  This means not using medical tests and procedures that are unlikely to help a condition or illness, or relieve symptoms.

Sounds simple enough, right?  But of course, it isn’t.  We all have a very hard time resisting just one more test, one more scan, one more round of treatment. What we really want is a different diagnosis and there is always the faint hope that another test will give us a better answer, a less difficult disease, a brighter prognosis.  Physicians work hard to maintain our trust and keep our spirits up, so they, too, fall into the trap, ordering test after test without enough much consideration of the risks and costs as related to the benefits.

Choose Wisely is based on the findings and recommendations of  nine specialty groups.  Each of the groups drew up a list of ‘Five Things Physicians and Patients Should Question‘, focusing on the drug therapies, tests and procedures in their particular specialty that are often overused – to no good end.

“The hope is that the lists will spark discussion between clinicians and patients about the need — or lack thereof — for many frequently ordered tests or treatments,” wrote ABIM President Christine Cassel, MD, along with James Guest, JD, the president of Consumer Reports. 

Below are the lists of overused treatments and tests from the first nine specialties that are participating in the Choose Wisely project.  Eight more societies have since joined and their lists will be released in the fall of 2012.

45 Things Physicians and Patients Should Question

American Academy of Allergy, Asthma and Immunology

  • Sinus CT scans and antibiotics for uncomplicated acute rhinosinusitis — the condition is almost always caused by viruses and usually resolves without treatment.
  • IgG and IgE testing for allergies — the only proven diagnostic blood test is IgE for specific allergens based on the patient’s clinical history.  Indiscriminate IgE batteries should be avoided.
  • Replacement immunoglobulin therapy for recurrent infections — such treatment is warranted only when antibody responses to vaccines are clearly impaired.
  • Routine diagnostic testing for chronic urticaria — definite causes are rarely identified and extensive testing is unproven to improve outcomes or to be cost-effective.
  • Diagnosing or managing asthma without spirometry – symptoms alone are not sufficient for a diagnosis and may overestimate as well as underestimate asthma control in treated patients.

American Academy of Family Physicians

  • Imaging for low back pain — unless certain ‘red flags’ are present, such as severe neurological deficits, imaging is rarely helpful in episodes of less than six weeks’ duration.
  • Antibiotics for acute mild to moderate acute sinusitis – as the AAAAI  (above) indicated, the condition is usually viral and resolves on its own.
  • Annual ECG or other cardiac screenings — false positives are common enough that the risks fail to outweigh the benefits in patients at low risk for cardiovascular diseases.
  • DEXA scans for osteoporosis — the minimum ages for which bone density measurements are proven useful are 65 in women and 70 in men unless risk factors are present.
  • Pap smears — cervical abnormalities in women younger than 21 are usually transient and no benefit from screening can be expected in women who have had hysterectomies for noncancer diseases.

American College of Cardiology

  • Stress cardiac imaging and other advanced imaging — these are indicated only in patients with symptoms or high-risk markers such as high Framingham scores or diabetes.
  • Regular stress cardiac imaging and other advanced imaging in asymptomatic patients during routine follow-up — such testing rarely alters management plans, except in patients more than five years after CABG.
  • Stress cardiac imaging and other advanced imaging during preoperative assessment for low-risk, noncardiac surgery — testing seldom changes management or improves outcomes.
  • Stenting of nonculprit lesions during PCI for uncomplicated hemodynamically stable ST-segment elevation MI — in such patients, the procedure increases risk of complications and early death with little proven benefit.
  • Echocardiography for routine follow-up in patients with low-risk native valve disease – this type of imaging is helpful only when indicated by a change in signs or symptoms.

To be continuedSpecial thanks to John Gever, Senior Editor, Medpage Today.


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