Choosing Wisely, Continued…

We continue today with the lists of medical tests and treatments that are too often overused, ordered and endured without much consideration for the risks and costs relative to their benefits.  These lists were drawn up by the medical specialties themselves, as part of the effort to reduce waste and needless harm in our healthcare system.

For example, the number one overused test on the list compiled by the American College of Radiology (ACR) involves imaging scans for uncomplicated headache.  The top unnecessary test for the American College of Physicians (ACP) is the routine or automatic screening of healthy-seeming, low-risk people with exercise ECG tests.  These tests are most unlikely to alter symptom management, increase the chances of treatment success or improve patient outcome.

Here are the rest of the results:

45 Things Physicians and Patients Should Question, continued…

American College of Physicians

  • Exercise ECG screening — there is no evidence that routine screening improves outcomes in low-risk, asymptomatic individuals.
  • Imaging in patients with nonspecific low back pain — it is not shown to improve outcomes.
  • Brain CT or MRI after simple syncope — unless neurological exams show abnormalities, there is little likelihood that imaging will reveal a cause.
  • Imaging studies for VTE as the initial test — high-sensitive D-dimer testing excludes VTE and is the preferred initial test unless there is a high pretest probability of VTE by Wells prediction rules.
  • Routine preoperative chest radiography of any type — unless patients have cardiopulmonary symptoms, chest radiography is rarely informative.

American College of Radiology

  • Imaging for headache — in the absence of specific risk factors for structural problems, imaging studies are unlikely to alter management.
  • Imaging for suspected pulmonary embolism — patients should have moderate or high pretest probability before imaging studies are warranted.  Perform D-dimer testing first.
  • Routine preoperative chest radiography of any type — unless patients have cardiopulmonary symptoms, chest radiography is rarely  informative.
  • CT scans for suspected appendicitis in children — consider first performing an ultrasound, which reduces radiation exposure and is nearly as accurate in experienced hands.
  • Follow-up imaging for adnexal cysts — small simple cysts are common and rarely of clinical consequence.  Imaging is warranted only for simple cysts larger than 1 cm in postmenopausal women or 5 cm in women of reproductive age.

American Gastoenterological Association

  • Long-term acid suppression for treatment of GERD — dose reductions should be attempted to find the lowest effective dosage needed to control symptoms.
  • Repeat colorectal cancer screening after a negative colonoscopy — in patients without high-risk factors, 10 years is the recommended interval for repeat screening by any method after a negative colonoscopy.
  • Repeat colorectal cancer screening after minor positive findings from colonoscopy — five years is the recommended interval in patients after removal of one or two small polyps without high-grade dysplasia.
  • Repeat endoscopy after diagnosis of Barrett’s esophagus — when a second endoscopy has confirmed absence of dysplasia, subsequent screenings should not be performed for at least three years.
  • Repeat CT scans in patients with abdominal pain — in patients meeting Rome III criteria for functional abdominal pain syndrome, repeated CT scans are unwarranted unless clinical findings or symptoms have changed.

American Society of Clinical Oncology

  • Cancer-directed therapies for solid tumor cancers in very ill, poor-prognosis patients — these are rarely effective unless patients have specific characteristics suggesting a favorable response to a given therapy.
  • PET, CT, and radionuclide bone scans in staging early prostate cancer — there modalities are helpful only in patients at high risk for metastasis.
  • PET, CT, and radionuclide bone scans in staging early breast cancer — as with early prostate cancer, advanced imaging is helpful only in patients at high risk for metastasis.
  • Routine biomarker testing and advanced imaging in asymptomatic breast cancer survivors — in breast cancer patients treated with curative intent, monitoring with serum biomarkers or imaging generally offers no benefit.
  • White cell stimulating drugs for preventing febrile neutropenia — these have not been proven effective in patients with less than 20% risk of developing the condition.

American Society of Nephrology

  • Routine cancer screening in late-stage dialysis patients – unless patients with limited life expectancies have specific symptoms, screening them for cancer has no value.
  • Erythropoiesis stimulating agents in CKD patients – these should be given only to patients with clinical symptoms of anemia or who have hemoglobin levels below 10 g/dL.
  • NSAIDs in patients with CKD, heart failure, hypertension, or diabetes — in these patients, other painkillers such as acetaminophen or short-term, low-potency opioids are likely to be safer than and as effective.
  • Placement of peripherally inserted central catheters in stage III-V CKD patients – arteriovenous fistulas are generally preferred for dialysis access, with fewer complications and lower mortality.
  • Routine chronic dialysis – initiating chronic dialysis should be an informed, careful decision shared by patients and their families as well as physicians.  Chronic dialysis may not improve outcomes in older patients with severe comorbidities.

American Society of Nuclear Cardiology

  • Stress cardiac imaging and coronary angiography — these are demonstrated to be helpful only in patients with cardiac symptoms or markers of high risk.
  • Cardiac imaging of any kind – only patients with risk factors are likely to benefit.
  • Routine radionuclide imaging during follow-up — again, this modality is unlikely to be informative unless patients show specific symptoms.
  • Cardiac imaging for preoperative assessment for noncardiac surgery — this, too, seldom alters management or outcomes in patients with low or intermediate risk for cardiac complications from surgery.
  • Radiation-based cardiac imaging of all kinds — in every patient, physicians should compare with reasonably expected benefits of imaging with the risks of radiation exposure, and should reduce such exposure whenever possible.

Special thanks once again to John Gever, Senior Editor, MedPage Today.

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